Electricity Generation
	 — 
	Question

The Lord Bishop of Chester: To ask Her Majesty’s Government what proportion of United Kingdom electricity consumption was generated abroad in the last year for which statistics are available.

Baroness Verma: My Lords, between October 2013 and September 2014, electricity imported into the United Kingdom was 7% of total electricity consumption. Electricity interconnection strengthens our security of supply and can lead to lower bills. Its flexibility supports renewable electricity generation. Greater interconnection means we can export excess power and import at times of stress.

The Lord Bishop of Chester: I thank the noble Baroness for that reply, although 7% seems quite a large figure. What assumptions are made for the availability of imported electricity to meet our peak demand? What contractual agreements are in place to undergird the availability of that supply?

Baroness Verma: My Lords, the right reverend Prelate raises an important issue about making sure that we have supply available all the time. The investment framework we have introduced means that we are getting on board two new interconnectors. They will make their final investment decisions this March. We realise that we need to do much more and that is why we have looked at the interconnectors as part of a programme that enables energy supply when it is needed most.

Lord Lawson of Blaby: My Lords, so far as indigenous energy resources are concerned, can my noble friend the Minister confirm that it is the Government’s policy to encourage the most rapid, practicable exploration of our UK shale gas resources? In that context, will she join me in deploring the unreasonable delays currently imposed by Lancashire County Council?

Baroness Verma: My Lords, my noble friend is of course a great advocate of shale gas, which offers huge potential for adding to the UK’s energy source but we need a diverse mix of energy supply. As a Government, we have tried to remove many barriers
	that get in the way of exploration but we have to work very closely with local communities to ensure that they come on board.

Baroness Liddell of Coatdyke: My Lords, further to that point about shale gas, one of the main reasons for the interconnector clicking into the UK direction is the rather dodgy state of our generation capacity at the moment. Given the glut of oil and the impact on oil prices, which knocks on to gas prices, what discussions have the Government had with the major generators about their long-term projections now and their choices for sources of generation? That impacts on shale gas and shale oil because the cost of exploration and production is not cheap.

Baroness Verma: My Lords, the noble Baroness’s point is well intended. As she rightly says, we need to look at the long term. While we have a drive-down of prices today, we need to see how the longer-term picture will encapsulate all energy supplies. That is why I am really pleased that this Government at least took the decision to make a greater diversity of energy supply available through the Energy Act 2013. That enabled the renewables sector to come and work on a par with traditional fuels. However, we have to make sure that whatever we do and whichever source we try to promote—in this case, shale offers huge potential—we support all supplies that make us less dependent on imported energy.

Lord Teverson: My Lords, I congratulate the Minister and the Government on revitalising the interconnector debate. Given that this is a way to reduce the cost of a decarbonised electricity system in the UK, what is happening specifically about negotiations with the Government of Iceland, where a huge amount of geothermal and hydro power is available? I understand that there are difficulties with European regulations in allowing the interconnector market to go ahead. What are the Government doing to renegotiate some of those rather unhelpful single market rules?

Baroness Verma: My noble friend is absolutely right: Iceland has vast geothermal, hydro and wind resources. We stand ready to liaise further with the Icelandic Government to determine the potential for interconnection in future that will benefit both countries.

Lord Elis-Thomas: My Lords, the Government of Latvia have announced the formation of an energy union within the European Union as one of their priorities for their term in the presidency. Can we have an assurance in this House that that will be fully supported by Her Majesty’s Government in the United Kingdom?

Baroness Verma: My Lords, this Government have been supportive of making sure that the UK is well managed within its own production at home, but of course we need to ensure that our European partners are also rising to the game. We are working very hard with our European partners to make sure that they are as ambitious as we are.

Lord Oxburgh: My Lords, the Minister will know that this country is now the largest external supplier of electricity to Germany through the interconnectors. At times of high pressure on electricity supplies in Europe, how and by whom is it decided in which direction the electricity flows down the interconnectors? Is that simply a matter of market forces and, if the prices are higher in Germany, do the lights go out in the UK?

Baroness Verma: My Lords, let me reassure the noble Lord that the lights are not going out.

Noble Lords: Oh!

Baroness Verma: We have enough capacity here. As the noble Lord is fully aware, Ofgem has worked very hard to ensure that the balanced reserves are in absolutely the right place. Yes, our margins have tightened somewhat, but that is not unusual; it has happened in the past. We currently have four gigawatts of interconnection. We are looking, through the least regret scenario, to introduce another five gigawatts of interconnection. Noble Lords should be reassured that this Government are taking that very seriously.

Lord Elton: My Lords—

Baroness Worthington: My Lords, the Minister is correct to say that the lights are not in imminent danger of going out. Interconnectors are increasing and delivering, demand for electricity is going down and gas prices are softening, so there is no imminent danger. However, we now find ourselves in a strange situation where we are paying old polluting coal stations to stay open at the same time as paying to close them. When will the Government address that anomaly?

Baroness Verma: My Lords, the noble Baroness is absolutely aware that we need to ensure that we are also being cost-sensitive to the consumer. Consumers cannot be bearing the brunt of us closing plants down and putting the prices up.

Lord Howell of Guildford: My Lords, I declare an interest as an adviser to Mitsubishi Electric. My noble friend mentioned interconnectors; does she agree that it is not just a question of the Iceland possibility? We could get electricity from Norway and Denmark, wind electricity from Ireland, or via other interconnectors from France and Belgium. Does she agree that all these prospects are there and could contribute vastly to our electricity supply, and will she confirm that the Government are encouraging all of them?

Baroness Verma: I am extremely grateful for my noble friend’s intervention. Yes, of course those countries are very important to us and, through the cap and floor regime introduced by Ofgem, we have seen five interconnector projects in its first application. There is a lot of good work going on with the interconnectors.

Transport: Shared Space Crossings
	 — 
	Question

Lord McAvoy: To ask Her Majesty’s Government what is their assessment of the impact of shared space crossings on the safety of blind and partially sighted people and other people with a disability.

Baroness Kramer: My Lords, the safety of all road users is of paramount importance. Our guidance on designing shared spaces makes it clear that the needs of all groups, including disabled people, must be considered during development. The design of shared space schemes, including types of crossing and assessment of safety implications, is for local authorities to determine. We have circulated guidance headed “Access for Blind People in Towns”, provided by the National Federation of the Blind, to 3,300 local authority and practitioner contacts.

Lord McAvoy: My Lords, I thank the Minister for her full Answer. Recently I met with a delegation of people from Gloucester, including a Mr Bill Waddell from the partially sighted and blind organisations and I have become aware, having since done a bit of work on it, that there is extreme anxiety among that community about the impact of shared space crossings on them. Will the Minister be willing to meet with me and a representative from the Royal National Institute of Blind People to discuss further how we can assist that community in making sure that they do not feel discriminated against? If the Minister is also agreeable to it, I suggest that we include the noble Lords, Lord Low of Dalston and Lord Holmes of Richmond, in that meeting.

Baroness Kramer: I would be absolutely delighted to meet. I meet the RNIB quite frequently, and if the noble Lord could ask whether it could bring me an update on the guide dog puppy Kramer, that would be really appreciated.

Lord Holmes of Richmond: My Lords, Blackpool has done a U-turn and Gloucester and Warwick have also done a U-turn on shared space crossings. What advice would my noble friend the Minister give to any authority contemplating these architectural conceits and planning follies—these health and safety disasters?

Baroness Kramer: My Lords, as you know, the Government provided detailed guidance in a publication in 2011, which was based on extensive research. As I said, we have also made available to all relevant groups the advice from the National Federation of the Blind, which covers these kinds of issues. However, I would point out that well designed shared space can work for people. For example, for those who have mobility issues or use a wheelchair, the removal of kerbs can be a tremendous advantage, so it is important that they are very well designed and, obviously, that equality law prevails in this area.

Lord Davies of Oldham: My Lords, one of the sites that received enormous attention was Exhibition Road, between the museums in South Kensington. Over Christmas time I sought to escort three grandchildren, all under the age of 10, out of the Science Museum to the V&A. They moved out into a road which was absolutely tenanted by pedestrians, because the museums are enormously popular, but the other side of the road was temporarily free of pedestrians and then one car and one taxi went past at about 30 miles per hour—the speed limit is meant to be 20. We cannot possibly have a situation where the speed limit is not maintained and surveyed carefully in these spaces; otherwise, pedestrians are greatly at risk.

Baroness Kramer: I would be very happy to try to encourage enforcement. That is obviously part of the programme which should be in place.

Lord Bradshaw: I rather agree with the Minister that local authorities are best placed to deal with these matters, but one change that the Government could make would be to ensure that all bicycles had a bell on them. That measure could be very cheap, and it would be very effective in preventing accidents between all sorts of people.

Baroness Kramer: My Lords, it is true that very often there is a tension between cyclists and pedestrians of various kinds. I do not have a good answer for him, but I will investigate and write.

Ukraine
	 — 
	Question

Lord Spicer: To ask Her Majesty’s Government what is their most recent assessment of the position in Ukraine.

Baroness Anelay of St Johns: My Lords, we remain very concerned about the situation in eastern Ukraine. While the verbal ceasefire agreed on 9 December has led to a decrease in shelling and casualties, Russia continues to supply the separatists with weapons and personnel. We welcome recent diplomatic activity and we hope that the talks scheduled for mid-January in Astana will result in all parties fulfilling the commitments that they made in Minsk in September.

Lord Spicer: My Lords, is not the stark reality that so far diplomacy has failed, that economic sanctions have made Mr Putin more aggressive rather than less and that the West will have to be prepared to engage in a Cold War with Russia and to rearm accordingly?

Baroness Anelay of St Johns: My Lords, I do not adopt my noble friend’s route to rearming and I am not as pessimistic. Perhaps that is because I am ever hopeful and because I am impressed by the level of diplomacy delivered through our Foreign and Commonwealth Office as well as through our colleagues throughout the European Union, the United Nations
	and the Commonwealth, all of whom have a common view. Yesterday the Prime Minister met Chancellor Angela Merkel and in his press release he made it clear that we continue to stand by Ukraine and that, although he and Chancellor Merkel regretted the fact that this was a second G7 summit without Russia,
	“We both want to find a solution to this crisis ... Russia is rightly feeling the cost of its illegal actions … And … we’ll be discussing how we try and keep up the pressure”.
	The Normandy format talks that are expected to take place next week, on 15 January, in Astana are promising and deserve to be given a chance.

Lord West of Spithead: My Lords, the Minister will be aware of the huge increase in Russian defence expenditure, particularly on its whole nuclear triad, with brand new ballistic missile submarines, a brand new ballistic missile and a brand new attack submarine with a new cruise nuclear weapon, while it is also running its nuclear trains again—all the indicators that during the Cold War would have had me terrified as Chief of Defence Intelligence. There is also the articulation of Putin’s policy of de-escalation, which in fact, when you read it, is talking about nuclear escalation. Is it not time to inject a sense of urgency into these talks? We are constantly getting near misses over the Baltic. Things are very risky indeed and we need to have proper talks, fully involving the Russians, who I believe have a real and proper interest in the Ukraine. We also need to give a sense of realism to some of the Ukrainian expectations. We need to get this going quickly with everyone involved, including the Russians, otherwise we might move towards a scenario that none of us would like.

Baroness Anelay of St Johns: My Lords, I entirely sympathise with the noble Lord’s views. The talks that are expected to take place next week will indeed involve the Russians with Mr Poroshenko, Monsieur Hollande and Chancellor Merkel, and those talks deserve to be given a chance. The Russians are feeling the brunt of sanctions, as they should for their illegal occupation of Crimea and for what they are doing in sending their troops into eastern Ukraine and making the humanitarian situation there worse. Diplomacy can be a strong tool—let us ensure that it is.

Lord Hannay of Chiswick: My Lords, does the Minister not agree that an absolute precondition for any change in sanctions has to be that Russia observes the commitments that it entered into in Minsk and that those commitments are verified by international organisations such as the OSCE? Could she perhaps say how she would characterise the proposition that if we had not been so beastly to Mr Putin, he would be behaving a lot better?

Baroness Anelay of St Johns: My Lords, I entirely agree with the noble Lord’s proposition with regard to the fact that the Minsk protocol must be adhered to by Russia; it must have oversight by the OSCE. It is absolutely clear that being beastly to Mr Putin has been no part of this country’s activity. We have sought to make sure that Russia keeps within its international
	commitments and international law, to which it has signed up. Nobody is to blame for what is happening to Russia now except Mr Putin.

Baroness Falkner of Margravine: My Lords, does my noble friend accept that a political collapse in Ukraine will have not only profound security but also economic consequences for the entire West? Will she therefore tell the House why the international and multilateral institutions are being so very cautious in putting in place a Marshall plan for Ukraine? If the Ukrainian Government collapse, it will be too little, too late if this caution continues to prevail.

Baroness Anelay of St Johns: My Lords, I am sure that my noble friend is aware that the IMF has been carrying out a study within Ukraine. It was clear when the Ukrainian Government put forward their first budget, which was adopted by the Rada, that there was a shortfall—it did not properly reflect the need for international activity. We are now waiting for the IMF to report on its findings before we can make further estimates about what action to take. I understand entirely why my noble friend is so concerned.

Lord Cromwell: My Lords, I declare an interest as reflected in the register. Will the Minister agree with me that the winner of this argument will be the party that brings economic development in particular to western Ukraine rather than picking fights with the Russians and their friends in the east?

Baroness Anelay of St Johns: My Lords, we are not picking fights with the Russians; it was the Russians who invaded and took Crimea. We are simply making sure that we hold them to their international obligations. The noble Lord is right to point to the importance of the development of Ukraine, but first, of course, they have a lot to do in addressing reform in their country, in particular corruption.

Lord Anderson of Swansea: My Lords, is the Minister confident that the West and the international financial institutions are geared to prevent an imminent collapse of the economy of Ukraine? The conventional figure being bandied around is $27 billion, but she may have noticed in this morning’s Financial Times that George Soros was talking about $50 billion and saying that the defence of the economy of the Ukraine is effectively the defence of the West. Are we geared to respond adequately?

Baroness Anelay of St Johns: My Lords, we are watching very carefully what will happen when the IMF reports. The noble Lord, Lord Anderson, is absolutely right to draw attention to what could be a very severe development and I am aware of Mr Soros’s article this morning. However, until we see the assessment by the IMF, it would be improper of me to make a guess as to what action we should take. It is clear, however, that we and our allies across Europe and in the United States are determined that Ukraine should be able to continue to receive proper support.

Lord Howell of Guildford: My Lords, just as “General Winter” did for Napoleon in Russia, is there not a good chance that “General Oil Price” will do the same for Vladimir Putin?

Baroness Anelay of St Johns: My noble friend is far more expert in matters of energy and oil prices, but we have all noticed the drop in the oil price to below $50 a barrel, which is having a severe effect on the Russian economy. However, certainly as far as Mr Putin is concerned, with regard to Ukraine there is a straightforward answer to achieving the relaxation of sanctions, which is to abide by the Minsk protocol and to remove his troops from a sovereign state.

Lord Dykes: Does my noble friend heed the wise words of the noble Lord, Lord West, earlier on in these exchanges about no excessive overreaction in the West, bearing in mind that Russia—not only Putin, but many people in Russia—feel very resentful about American triumphalism after the collapse of the Soviet Union, with overreaction, threats of new missiles and so on? The whole long litany of mistakes made by the West has caused Russia to find excuses for bad behaviour.

Baroness Anelay of St Johns: My Lords, given that Mr Putin invaded a sovereign state and has seized part of that sovereign state, where the humanitarian situation, in particular for Crimean Tatars, is deteriorating, our response has been moderate and proportionate.

The Lord Bishop of St Albans: My Lords, we must not forget those Ukrainians living in Crimea who now find themselves under the Russian state. Could the Minister update us on what representations have been made on their behalf and, in particular, whether the OSCE monitors have made any progress in gaining access and finding out what is going on?

Baroness Anelay of St Johns: My Lords, the right reverend Prelate is right to raise these issues. We are still trying to ensure that the OSCE monitors gain access to Crimea, as they should be permitted to, but there have been many obstacles in their way. We are aware that conditions for the Crimean Tatars have deteriorated. That is a matter of great concern, which is discussed by us and our allies across Europe with the ICRC and other humanitarian organisations.

Higher Education: Funding
	 — 
	Question

Lord Stevenson of Balmacara: To ask Her Majesty’s Government what assessment they have made of the long-term sustainability of higher education funding in the United Kingdom.

Baroness Williams of Trafford: My Lords, participation in higher education has huge benefits for both student and state, and that is why the English higher education funding system shares the cost of
	study. The system of grants and government-subsidised student loans, which are based on income-contingent repayment, has enabled us to maintain student numbers, and universities now have a sustainable income stream. In 2014, we have had record participation rates both for 18 year-olds and for disadvantaged students.

Lord Stevenson of Balmacara: I thank the Minister for that full reply. I thought that she would simply refer me to the Answer that she gave on 15 December to a very similar Question from her noble friend the noble Lord, Lord Sharkey. I have read the OECD report that she quoted on that occasion—in fact, she quoted it three times—to support her assertion that the coalition Government have a sustainable system of higher education funding. On page 261 of that report, the OECD notes:
	“Since 2009, further changes have been made to tuition fees and public support systems”,
	in the United Kingdom.
	“However, the data presented here … do not reflect these more recent changes”.
	In other words, since the tripling of university fees, the elimination of HEFCE’s teaching grant and the introduction of punitive interest rates for student loans, the OECD has actually made no statement about the sustainability or otherwise of the coalition Government’s present HE funding system, and it is surely disingenuous of Ministers to assert otherwise. In the light of this, would the Minister confirm that her quote was taken out of context from the OECD report, apologise for misleading this House and withdraw the comments that she made on behalf of the Government on 15 December?

Baroness Williams of Trafford: My Lords, to say that a Minister is misleading the House is quite a strong thing to say and should definitely be backed up by facts. I refer the noble Lord to a comment by Andreas Schleicher, the OECD’s director for education and skills, two days ago in an article, where he said that,
	“the UK offers still the most scalable and sustainable approach to university finance”.
	I wonder whether the noble Lord might in fact withdraw his comments.

Baroness Sharp of Guildford: My Lords, I declare an interest as a member of the Higher Education Commission, which questioned the sustainability of the system. Is the Minister aware that the IFS now reckons that, at £44,000, the average debt of UK students is higher than that of students in the United States? Is it really right that a teacher aged 35 should be unable to obtain a mortgage because of the debts that they still owe on their student debt? The typical average teacher is likely to be unable to pay off that debt throughout their career.

Baroness Williams of Trafford: My Lords, the way in which the repayment system is structured means that no student, when they complete their studies, should ever be at a financial disadvantage. No graduate has to pay back their loan until they achieve an
	earning of £21,000 a year. There should not be any fear of an inability to pay back for the postgraduate student.

Lord Morgan: My Lords, is there not a serious imbalance in university funding in terms of research, which has not been covered so far? The biblical precept has been followed of “To him who hath, more”—much more—“shall be given”. The effect is that only a small number of large, highly endowed universities are able to conduct a full research programme and be research active. Is it not seriously damaging to higher education in this country that our financing of research should be based on this inbuilt inequality?

Baroness Williams of Trafford: The noble Lord is absolutely right that research is fundamental both to universities and to the economic future of the country. I refer him to the Chancellor’s Autumn Statement, in which the Chancellor announced a significant amount of new money for research.

Lord Foulkes of Cumnock: My Lords, the Minister’s reply implies that the system of university funding is the same throughout the United Kingdom. That is clearly not the case: there is an entirely different system in Scotland. Would she consider the UK Government and the Scottish Government setting up a joint investigation into the cost-effectiveness of both systems and reporting to both Parliaments?

Baroness Williams of Trafford: My Lords, that is possibly a matter for the devolved Administrations to decide.

Lord Sutherland of Houndwood: My Lords, since the changes in the funding of universities have taken place, one of the problems which has come to the surface is the funding of postgraduate students. That is because undergraduates graduate and leave with a fairly large debt, which makes them unready, unwilling and perhaps unable to fund further postgraduate work. Will the noble Baroness go back to the department and look at how we can deal with this?

Baroness Williams of Trafford: My Lords, the noble Lord may be aware that the Chancellor recently announced that, from 2016, postgraduate students will be able to get a loan of up to £10,000 for their studies.

Lord Elystan-Morgan: My Lords, is it not the case that Her Majesty’s Government have made an assessment of what proportion of student loans are likely to be recoverable? Will the noble Baroness tell the House what that figure is?

Baroness Williams of Trafford: My Lords, that figure varies—I think that my noble friend is referring to the RAB charge—because of macroeconomic factors such as earning potential and, therefore, the ability to repay. It is currently estimated to be around 45%.

Baroness Walmsley: My Lords, how many mortgage lenders are taking student loans into account when considering applications for mortgages?

Baroness Williams of Trafford: I do not know the answer to that question but am very happy to write to my noble friend.

Lord Winston: My Lords, I was astounded to hear the Minister suggest that research in universities is properly funded when in fact they have laboured because the research councils have supported flat cash for the last five years, so there has been no adjustment at all for inflation. That has had a very serious effect on all aspects of research, including postgraduate education.

Baroness Williams of Trafford: My Lords, the point I made was that the Chancellor announced a significant amount of funding for research in the Autumn Statement.

Business of the House
	 — 
	Timing of Debates

Moved by Baroness Stowell of Beeston
	That the debates on the Motions in the names of Baroness Massey of Darwen and Lord Turnberg set down for today shall each be limited to two and a half hours.
	Motion agreed.

Early Years Intervention
	 — 
	Motion to Take Note

Moved by Baroness Massey of Darwen
	That this House takes note of the case for early years intervention in breaking the cycle of deprivation and promoting social mobility

Baroness Massey of Darwen: My Lords, I am delighted to have secured this debate and, with it, an array of knowledgeable and talented speakers. In this election year, I hope that the issue of early intervention and improving the life chances of children will be high on the agenda of all political parties. It may even win votes. Without such intervention, children will suffer in terms of education, health and the acquisition of skills. That deprivation will continue to impact on social life and economic prosperity.
	Research by charities, academics and politicians clearly indicates the connections between early years intervention and future economic mobility. The splendid work of children’s charities gives us valuable insights into the needs and implications of early intervention. Research from Tickell, Munro, Coughlan, Field, Allen and the Rowntree Foundation—to name but a few—is clear and forceful, and the all-party manifesto for intervention in the nought-to-two age range is a call to action.
	There are many reasons for deprivation and lack of social mobility. There are particular children and families who need extra help—the disabled, those with poor health conditions or language skills, those in care, those who have experienced violence and those who
	are poor. I shall refer later to an ongoing Scottish programme, the Early Years Collaborative, which is an interesting model of successful intervention.
	Just before Christmas I was struck by two news items. One involved the damning findings of an OECD report pointing out the link between inequality and growth in the UK. Those concerns were echoed by the Office for National Statistics. The UK has lower levels of intergenerational earnings mobility compared with other OECD countries. In fact, we have the worst performance and are way behind the Nordic countries, Canada and Australia. It is estimated that the UK economy would have been more than 20% bigger had the gap between rich and poor not widened since the 1980s. It is a shocking indictment of our society. The second news item, and indictment, was a statement by the former Archbishop of Canterbury, George Carey—the noble and right reverend Prelate Lord Carey—that parents were giving up food so that they could feed their children and were suffering levels of hardship not seen in Britain since before the NHS was created in 1948. How depressing and debilitating.
	We cannot ignore the evidence that social mobility in the UK is poor and that we need to look at early intervention as a way of combating the situation. Graham Allen MP has called for decisive leadership at the political level and for effective planning and co-ordination to shift resources to early intervention. I agree. One thing is clear: unless Governments are very focused about early intervention, with precise and measurable targets and evaluation of outcomes, we will fail children and families. Unless Governments ring-fence funding for children we will fail those children. Unless Governments encourage services to work together nationally and locally to benefit children and families, we shall fail them. We have too many examples, from government departments to local services, of lack of co-ordination and slow action which we should not ignore—for example, in sharing data about children and the joint commissioning of services. There are also, of course, examples of good practice, but this practice is often not shared because there is no strategy for doing so. It is a waste of money and resources. Does the Minister agree?
	A key issue for children from birth onwards is developing confidence, self-esteem and resilience. It is known—but rarely given enough emphasis—that social and emotional skills, as well as academic skills, are important for success. It is known that succeeding at tasks—whether those tasks are academic, artistic, sporting or something else—helps to build a positive self-concept which protects against adversity and encourages the confidence needed to succeed. It is known that speech and language ability is essential for communicating and self-confidence and supports all learning. A University of London study has shown that children with higher levels of emotional, behavioural, social and school well-being have higher academic achievement, are more engaged in school and make more progress.
	Although material wealth is, of course, not necessarily a predictor of success, it is a powerful factor. As we know, poverty in families can mean depression and poor health and have long-lasting effects. By the age of 16, children receiving free school meals achieve lower
	grades than children who live in wealthier circumstances. Leaving school with fewer qualifications may mean—does mean—lower earnings or unemployment.
	I should declare that I am a member of the Select Committee on Affordable Childcare, which is so ably chaired by the noble Lord, Lord Sutherland. Although our deliberations are not yet complete, we have already found that the systems and structures of childcare which parents have to negotiate are complex and confusing. We have found variability in the provision and quality of services, which is often to the detriment of poorer areas, and we have found that there is often no advantage to middle and lower income families in going out to work.
	Ofsted has pointed out that only a little over one-third of children from low-income families reached a good level of development in 2013. Ofsted describes children’s centres as,
	“a sector that is characterised by turbulence and volatility”,
	where the accountability of the local authority may be seen as more important than that of children’s centres. Structures are changing, but often not for the better. We know that local authorities are spending less on children’s centres than they did in 2013-14, yet children’s centres can genuinely provide a place where education, health and well-being can be combined and where parents are supported. An earlier government report—the early years framework of 2011—speaks of the importance of retaining Sure Start centres, reducing bureaucracy and improving quality. The social mobility strategy of 2011 emphasised the need to encourage parental involvement, so it is ironic that all this is now at risk. Can the Minister comment?
	Child health is key to counteracting deprivation. In 2012, the Chief Medical Officer called her report Our Children Deserve Better. It stated that—an obvious point—what happens in early life is a predictor of what happens throughout life and that outcomes in the UK are poorer than in other developed countries in relation to morbidity, mortality and well-being. This carries enormous costs, both financially and to child development. The long-term costs of obesity and mental health in England are simply enormous.
	An initiative in Scotland called the Early Years Collaborative, which was begun in 2013, is the world’s first national multiagency quality improvement programme for children and families. Its stated commitment is to ensure that every baby, child and parent has access to the best possible support available. It seeks to shift the balance of public services towards early intervention and prevention by 2016. It is a coalition of community planning that involves all 32 community planning partnerships, including organisations such as social services, health, educators, the police and the third sector. Training of professionals and parents is a cornerstone. It involves children and families in testing ideas for improvement. The initiative has been described as a shift in culture and a social movement focused on early intervention. Results so far are promising in relation to the health, well-being and confidence of parents and children. The model has much to offer. Will the Minister look at this model and encourage his colleagues in government to do so as well?
	In order to break the cycle of deprivation and improve social mobility, there are some obvious priorities: improve parenting skills; make childcare simpler to manage, with clear standards and assessment measures; ensure that services such as health, education and social services work together at community level; and ensure that the Government provide clear leadership, with a stated emphasis on the prevention of problems rather than attempted cures for the consequences of problems later on. We have a fractured early years system that is a tangle of clumsy structures—that is not a criticism of those dedicated professionals who work in those structures, with whom I sympathise. Early intervention is absolutely key to improving health, well-being, learning and social competence; neglecting it is disastrous. I hope to receive assurances that the Government understand the problem. I beg to move.

Lord Freeman: My Lords, I congratulate the noble Baroness. She has tremendous experience, she has already made a great contribution and I hope that she will continue with her hard work.
	I would like to complement what the noble Baroness has said by concentrating on the nine to 11 year-olds—and, indeed, right up to school-leaving age at 16—because child poverty, in my humble judgment, is not to be defined simply in terms of the very early years. The impacts of economic poverty, and the poverty of guidance by parents, the local community and brothers and sisters, can last a lifetime and has to be addressed at different stages. The noble Baroness has aptly, and in a very clear way, concentrated in part on the very early years.
	My limited experience, when compared with the noble Baroness, dates back to the former Prime Minister Gordon Brown’s excellent initiative in commencing what became known as SkillForce when he was Chancellor of the Exchequer. Subsequently, the Ministry of Defence, and now the Department for Education, took up sponsorship, initially financially and now in terms of model support, for the work that SkillForce does. It is largely staffed by ex-service men and women, some of whom suffered injuries, and now works with 180 schools in the United Kingdom with 4,000 children. The children are aged between nine and 16. They are identified as disruptive children in school by head teachers.
	In part, they are disruptive because of child poverty. Very often they come from single-parent families. If a mother has to go to work in a supermarket, and has to leave very early and does not come back until late at night, one can imagine the depressing effect that that has on a child who is bussed back from school, particularly in rural areas such as East Anglia which I know very well. The child may travel long distances and go back to an empty home. Almost by definition, it will be a poor home. The experience of that type of poverty sometimes leads to disruption in class. That might affect only 5% of a class but it can affect the academic and social education, guidance and achievement of the rest of the class. That is where our staff, who, as I say, are mainly ex-service men and women, work very hard.
	The situation is excellently set out in your Lordships’ briefing pack, The Case for Early Years Intervention in Breaking the Cycle of Deprivation and Promoting Social Mobility, prepared by Heather Evennett. I commend it to noble Lords who wish to follow up this debate. The study makes the point that attention should not be age limited to the very early years but has to be given right through to age 16. I have been chairman of the trustees of SkillForce for more than 10 years. I am glad to say that it has had a dramatic impact on reducing the NEET—not in employment, education or training—figures for those who are under-privileged and, in the early years, in economic as well as social and parental poverty. I strongly support the achievements of SkillForce.
	I ask the Minister to comment on the likelihood of the United Kingdom receiving a substantial portion of the European fund that has been set aside by the European Union to deal with youth unemployment. The European Union Committee, on which I have had the pleasure to serve, has been monitoring progress, which seems remarkably slow. Any funds from Europe to help, in particular, 14 to 16 year-olds into employment—young people who might have no social skills and no background of employment—would be very helpful.

Lord Sawyer: My Lords, I thank my noble friend Lady Massey for introducing this extremely important debate. I have the good fortune to be a member of the Select Committee on Affordable Childcare, under the chairmanship of the noble Lord, Lord Sutherland of Houndwood, from whom we shall hear shortly. That experience has caused me to think about the subject of today’s debate.
	I have been surprised at the complexity of the issues surrounding the case for government intervention in early childhood education. Within that complexity are the varying approaches of hundreds of academics, think tanks and other organisations. It is an extremely complex issue. However, through all that complexity, what I have learnt is quite simple. In order to help break the cycle of deprivation and to promote greater social mobility, intervention in the home/learning environment at the earliest possible opportunity is absolutely essential. That includes the development of early speech, language and vocabulary, and recognition by professionals and parents that working with the young to stimulate early learning is both socially advantageous and deeply rewarding for parents, professionals and children. That is the number one thing that needs to be considered and promoted.
	I have also learnt that, in nursery and child-minding settings, getting the highest quality staff possible on the front line working with children from disadvantaged backgrounds is essential. That means accepting fully the recommendations of the Nutbrown review and investing in a better trained and qualified workforce, many of whom will need to work with disadvantaged children. The Government should target and champion the expansion of high-quality provision in the most deprived areas.
	I spoke this week to the head teacher at Abingdon primary school in the centre of Middlesbrough, a town which has provided excellent nursery education, who is experiencing great difficulty in coping with an expansion of parent-led demand in the inner city. She is unable to meet the demand because there are physical space requirements which she cannot afford. This means widening the gap between the children in the more affluent parts of the town and the inner core and increasing the cycle of underachievement and deprivation. That is the sort of thing that the Government could help with because targeted funding would have a major impact and effect on helping children in the inner city areas. If we do not do this we create differences in ambition and achievement at a very early age which will never be recovered.
	Government recognition of the problem and intervention will probably never be enough and the problems of the poor can never be resolved without the support of the better off. Although we received evidence in our committee that the cost of childcare in the UK is 33% of net household income compared to an OECD average of 15%, something tells me that there is not a lot of room for increased parental contribution from the better off. To get a better contribution from wealthier parents, we need to look more carefully at the way in which we organise work and at how we can enhance the lives of the more affluent. This means that employers should think a lot more about how professionals can do the job they are paid to do and also manage childcare at the same time. Good work is being done on this. Some companies are working more flexibly, with greater agility and sensitivity, so that people can fulfil their roles at work and also their family responsibilities. We all know about job sharing and reduced hours flexibility, but a culture where the success of a business is recognised by its having successful employees at work and at home is very important.
	I stopped being a trade union official 20 years ago. At that time I started to think about these kinds of issues but not in the fully-developed way in which I think about them now. Today, in unionised and other workplaces, childcare and early education should be at the top of the bargaining agenda. I thought about it a little 20 years ago but now I am fully full steam behind it. As with sickness, health and safety, pensions and all the other things that enhance the lifestyle of people at work, the bargaining agenda, with or without unions, should involve the quality of their lives. That is very important. For the almost 7 million lone working parents with dependent children, it is almost a necessity. A recent survey showed that half of these parents are unable to leave work on time and cannot eat with their children, so for them this is a necessity, and for the growing number of young fathers who are resentful about their work/life balance, it is also a necessity.
	We have a lot of work to do with employers, businesses and Government to try to get people to think a lot more about how they can be successful in their careers and also take full responsibility—men and women—for childcare.

Lord Storey: My Lords, I, too, thank the noble Baroness, Lady Massey, not only for securing this debate but also for all her work with young people and on education. We know from almost every report which has looked at the issue of how to deal with the problem of social mobility—in my day we called it “life chances”—that there are two main things that we can do. One is about poverty and the other is about early years provision and the opportunities for intervention at a very young age. Children who are exposed to quality childcare and early years provision have improved outcomes. There is no argument about that, and those outcomes are also better in their adult life. Most important, the positive impact of high-quality childcare is more pronounced in those who start out behind their peers; that is, those with less educated parents, from lower income groups or with English as a second language. We know that as a fact.
	What can we do? We have to make sure that we get early years education right. The social benefits for individuals and for society as a whole mean that it is of paramount importance to do that. All political parties sing from the same hymn sheet on this, while successive Governments have done their bit. The last Labour Government brought in the hugely successful Sure Start centres, the early years foundation curriculum in 2006, and free entitlement to part-time provision. This Government brought forward through the Children and Families Act 2014 early years educator and teaching qualifications, plus 15 hours a week of free pre-school care and education for the most disadvantaged. I will come back to that in a moment, if time permits.
	I have six steps that we should take now. They are not controversial or difficult and they do not cost a lot of money, but they would enhance what we do. The first is this. Every indicator in reports and from practice overseas shows that the presence of high-quality staff boosts the quality of the care delivered, and the impact is greatest when staff spend a substantial amount of their time interacting directly with children and they are responsible for the curriculum. We do not want to see graduates working in early years education filling in forms but working with children so that their passion can be shared with other staff.
	Secondly, from the perspective of child development alone, it is better to prioritise access to high-quality care from an early age. There should be more provision at 18 months to two years and increased hours for three to four year-olds. If we get it right for younger ages, it has more of an impact. If resources are limited, we know where they should be spent.
	Thirdly, early years provision needs to resist “schoolification”. We do not want the early years to be a carbon copy of primary and secondary school. Yes, get children ready for school, but they should be able to learn through discovery and exploration and by using their imaginations. Those are all hugely important in the early years. We should resist any move to dress up our little tots in school uniforms, give them pens and paper and sit them down to learn to read and write. That is not for the early years, and actually it is very damaging indeed.
	Fourthly, early years provision should engage with parents because they are the other side of the coin. That is why the Sure Start centres were so important; they engaged with parents. Early years provision that engages with parents has a positive influence on the home learning environment. Early years settings that encourage parents to read stories to their children and sing songs and encourage the children to paint and to play with friends have hugely important developmental benefits for children.
	Fifthly, we need to ensure that the provision is of the highest quality. Yes, Ofsted is there to monitor and to judge, but it is not best placed to improve standards. That has to be done by others. Local authorities have a huge role to play in improving standards in early years, for example in training and development, which is really crucial.
	My last point, the sixth of my six steps, is for children from 18 to 36 months. Cognitive development for older toddlers is best supported in lower-ratio formal group provision. More hours in centre-based care for two to three year-olds is associated with better language skills and better maths, leading to higher academic outcomes in primary schools.
	Those are the six steps, but I will add one other point, which I think another noble Lord mentioned. This is very complicated for parents. We need to make sure that it is very simple and that parents know how to access early years—it needs to be clearly signposted, but we use all these different phrases and words. I went to the launch of Ofsted’s last early years report, which made the very same point: we use different terms for early years. Let us use one term so that we can be clear about it and make sure that parents can access it.
	My final point is that I would like somebody to come up with a different term from “childminders”, because “minding” a child is not what early years should be about. Perhaps the Minister could find a different term from “childminding”.

Lord Sutherland of Houndwood: My Lords, I would suggest “child carer” as an alternative to “childminder”, but that is for further discussion. I thank the noble Baroness, Lady Massey, for securing the debate on this very important topic. I also pay tribute to her for what she does in this area, which is much appreciated, in this House and far beyond.
	Just for the avoidance of doubt, I have the privilege of chairing the Select Committee which will report on this—we hope in good time in February—but my remarks today will not specifically be related to that report. There is another theme, or hobby-horse, that I want to ride, which is what I shall do today. To give your Lordships forewarning, that is the hobby-horse of language. The focus of what I have to say will inevitably be on early years intervention related to education in some way, but as the noble Baroness, Lady Massey, made plain, there are many elements to early intervention which have to come together, such as health, sociability and so on. I shall focus on the provision for issues related to language.
	There has been good progress in school education over the last two years in relation to STEM subjects, which has been very welcome and much appreciated
	across the community. There is a growing awareness of the importance of language in the sense of learning a second language, be it Mandarin or Spanish. That is progress and should be encouraged. However, my focus today is to add language in the broader sense to that list where there has been progress. If you talk to primary school teachers, particularly those in reception classes and certainly those who are now dealing with three and four year-olds, you will discover very quickly that they have a distinctive set of issues and problems to face. Their work is very rewarding, and some of them are exceptionally good and patient at it—I stress the word patient—but they face difficulties which are not so apparent later in the system. I do not just mean toilet training or teaching children to tie their shoelaces or button their coats, although all that is part of early intervention at an educational level.
	At the core of all this, I argue, is language. That includes, but should not simply focus on, second-language families. That is part of it and is an additional issue today, but this is about the question of learning the basic skills of communication, being sociable, asking and answering questions, making interventions or comments and securing the attention of the teacher when one is in difficulty. It has to do with commenting on and responding to what goes on in the classroom and what other pupils say. It has to do, basically, with getting away from the law of the jungle, which by and large most two year-olds inhabit, and if you have not got out of it by the time you start formal education you are in difficulty, as are your teachers and fellow pupils. It has to do with being part of a community or a tribe, not living just on the basis of what you can grab.
	This is a very subtle issue. For many children, this is not a problem. For many children, this is what they learn in the rough and tumble of the family, from having siblings and from playing with the kids next door. For many, it develops in due course through education. But I ask the Minister whether he perhaps might return to the department and ask questions about how we are focusing on the acquisition of the ability to communicate—language in that broad sense.
	The ways in which I think progress should be made were spelt out more than 250 years ago by David Hume and Adam Smith. Your Lordships might find this a bit esoteric and think, “Well, he did teach philosophy and we have to restrain him”, but Hume saw this process of socialisation as fundamental. It is not an add-on for as many human beings as you can manage; it is part of being a human being—being able to socialise, communicate, share and understand what others say but also what they desire and what they can reasonably expect. I will quote from one of the recent commentators on Hume’s close friend, Adam Smith. Nicholas Phillipson writes that Smith,
	“held that all our sentiments”—
	that is, emotions and beliefs—
	“– moral, political, intellectual and aesthetic – were acquired, developed and refined in the process of learning to communicate with others”.
	You do not learn language and then learn how to feel; the two go hand in hand, and unless adequate attention is paid to the development of communication, these things will also fail.
	This may seem very fluffy. It is not. It is fundamental. Look further up the system. In terms of social mobility, if you measure the number of people in prison who have deficient literary and mathematical skills, that is what you will find. It starts at this age.

The Lord Bishop of St Albans: I, too, thank the noble Baroness, Lady Massey, for pressing this very important issue. It is, as has already been noted, an extremely complex one. We are talking about nothing less than a profound culture change in many local communities if we are to break the cycle of deprivation and increase social mobility.
	For some years I worked in two parts of the West Midlands—wonderful places to live and work; I have many friends there still—but they were both characterised as areas that had extremely low aspirations. It was one thing to change the school but if the child went home and was told repeatedly, “Actually, that sort of thing does not make any difference to us. You are wasting your time”, all the work was undone. There needs to be a profound social and cultural change in the family as well.
	That was one of the things that struck me when I was reading the comments in the interim report of the All-Party Parliamentary Group on Social Mobility, which reported back in 2012. It summarised its conclusions into seven “key truths”. I will pick out just the first four, which show precisely this connection. The first key truth was:
	“The point of greatest leverage for social mobility is what happens between ages 0 and 3, primarily in the home”.
	The second and third were:
	“You can also break the cycle through education … the most important controllable factor being the quality of your teaching”.
	Then it flips back to the family in the fourth one:
	“But it’s also about what happens after the school bell rings”,
	and the child goes home.
	That same point was made very eloquently in the excellent cross-party report The 1001 Critical Days: The Importance of the Conception to Age Two Period, which was published last June. In other words, any approach needs to work not only with our schools but with everybody in the home—a parent or parents, and siblings—and every place in which the child and their family will find themselves in seeking to change that culture and that level of aspiration.
	We have some collaborative holistic models; for example, the outstanding work done in the Troubled Families programme. Louise Casey, who heads up the programme, was quoted in a report published last October. She said:
	“This programme is working so effectively because it deals with the whole family and all of their problems, with 1 key worker going in through the front door and getting to grips with an average of 9 different problems, rather than a series of services failing to engage or get the family to change”.
	We need some imagination about the practical ways that we can get holistic approaches working at every level of the family and the child’s life if we are going to
	break these cycles of deprivation and increase social mobility. It will need significant resources and people with first-class skills focused over the long term. I hope that, with a general election coming up, we will steady ourselves with some of the programmes that are now beginning to bear fruit and not simply ditch them and reinvent new ones all the time.
	I also plead that we work hard on establishing partnerships and close working relationships with the statutory and, more importantly, the voluntary and charitable sectors. I shall pick up on a couple of them. I have recently been in touch with the Stefanou Foundation, which is based in Welwyn Garden City, in my diocese. A major part of its work is entitled “Healthy Relationships: Healthy Baby”. It includes training in parenting. It has taken the lead in working with the police, local government, and health and probation services. It is about to launch a programme this April in Stevenage and in Westminster. It is a fascinating example of a group taking a lead on this and building on these connections, drawing in everybody to try to get this holistic approach so that we are getting some synergy, which seems fundamental.
	However, we should not forget the quiet, unsung work that is going on that probably never gets on anybody’s radar. I shall give an example. I was recently in one of my churches, Christ Church in Bedford. That parish church employs a full-time families worker called Monica Cooper. It has raised the money to do this. Most people in the area probably do not know what is going on. It is long-term work. Much of it is about teaching parenting skills. The result is that Monica has been able to support a number of families. The results have been quite notable for a small number of families. It is very intensive work. It means that some children who had more or less dropped out of school are now regularly attending school. The work has been commended by a local head teacher. It is long-term and costly. If we are to find a way forward, we need local authorities to deliver clearly focused work and to act as co-ordinating bodies, engaging with national and local charities, all pulling together in the same direction.

Lord Giddens: My Lords, when a technical concept in social sciences is imported into political discourse there are often problems. This has happened with the notion of social mobility. We must distinguish between what sociologists call absolute mobility on one hand and relative mobility on the other. Absolute mobility refers to changes in the labour market and occupational system that creates jobs for people to move into. Relative social mobility is the movement of individuals up and down the social scale. In principle, these two things are completely different. If we do not recognise this, we will never get appropriate policy in this area.
	Almost all the social mobility experienced between the 1960s and the early 2000s was absolute social mobility; that is, it depended on the expansion of white collar and professional jobs as deindustrialisation took hold. The number of blue collar jobs shrank dramatically. Rates of relative mobility—that is, individuals
	supplanting others who move up and down—remained low throughout this period and remain very low today. With relative social mobility, it is crucial to understand that for those at the bottom to rise up, others above them must experience downward social mobility. This does not happen very much, because privileged groups are normally able to deploy strategies to ensure that it does not happen and to keep ahead—that has important policy implications that I will come back to.
	For this reason, interventionist policies, no matter how well intentioned and designed to help individuals in a direct way, whether in early years or not, will never be more than of limited effectiveness. We have an awful lot of evidence on this: it comes especially from the Head Start programme in the United States, which was initiated as long ago as 1965 as part of the war on poverty. I can assure noble Lords that those results are immediately and directly consequential for and relevant to this country. Sure Start here was based on Head Start—one could say that the Americans had a big head start over Sure Start and put a lot more resources into it.
	I shall mention three conclusions, based on an awful lot of research—good intentions are not enough in this area. First, amazingly, as a result of many studies, there is no real consensus among academics on how effective the Head Start programme has been. Some studies show improvement in cognitive and behavioural skills; others find no correlation at all. A lot of money has been spent, but the level of feedback and the implicational consequences have been relatively low. It is really important to bear this in mind: as I have said, all policy must be evidence-based; it is not enough to be based just on good intentions.
	Secondly, where positive results are found, they tend to fade after a few years. This is known in the literature as Head Start “fade” and is a well established phenomenon. It means that you cannot just depend on early intervention. As at least one noble Lord mentioned, there must be subsequent interventions at other ages for these policies to work. This is clearly, plainly and empirically demonstrated; such policies have to stretch across the school years as a whole.
	Thirdly, the old idea that early years are somehow a magic phase of child development, decisive for later years, has to be abandoned, at least in the case of social mobility. They are not. The Government’s social mobility and child poverty strategy is therefore quite inadequate as it is set out.
	I have two questions for the Minister. First, active policies are needed to counter the strategies of affluent parents who try to ensure that their advantages are passed on to their children. This is a crucial mechanism whereby relative mobility is kept limited. The Prime Minister referred to such parents as the “sharp-elbowed middle classes”. Dare the Government stand up to the sharp-elbowed middle classes? You will not improve social mobility for people from poor backgrounds unless there is some kind of strategy along these lines.
	Secondly and finally, does the Minister agree that active intervention at the level of the labour market will be crucial to ensure that dead-end jobs do not produce an underclass where there is virtually no
	mobility at all? Inequality always trumps mobility, and it is intervention in the area of absolute mobility that will really make the difference.

Lord Northbourne: My Lords, like other noble Lords, I am most grateful to the noble Baroness, Lady Massey, for getting this debate and for the wonderful work that she does for children in all sorts of other contexts. I also congratulate the Government on recognising the crucial importance of each child’s early years and on introducing the early years programme, which I fully support.
	My contribution this afternoon is on one issue that your Lordships might think tangential—but it is fundamental. I do not believe that the early years programme alone as it is designed today will be enough to make a confident, committed and supportive parent out of a young person who has never known life in a secure and supportive family. We have a cycle of disadvantage to break.
	All secondary schools, especially those serving disadvantaged communities, should work towards a policy that helps as many teenagers as possible to develop not only their academic skills but also their self-confidence and personal, interpersonal and emotional skills—sometimes called the soft skills—to give them the character and resilience that they need in both the workplace and raising a family as they grow up. Such a policy, alongside appropriate academic education, could be a powerful agent to increase social mobility and justice in our society—concerns about which have been so clearly expressed by noble Lords already. We know that secondary schools can do this because the best ones are doing it today. Alas, too many are not. On the same issue of supporting young people as they grow up to become parents, weekly boarding for children from severely disadvantaged families can be immensely effective.
	These issues are touched on in two recent government reports published in November which I happened to find. The first is Social Justice: Transforming Lives—Progress Report. It says:
	“The family is the most important influence in a child’s life”,
	and that families are,
	“the bedrock of our society”.
	It goes on to discuss support for families but makes little or no reference to preparing young people in school for the responsibilities of adult life and parenting.
	The second report is the Government’s response to the second annual report of the Social Mobility and Child Poverty Commission. It says:
	“Children’s development in their early years provides the crucial building blocks for later life”.
	The recommendation was that the Government should give,
	“more focus to preparing children for the world beyond schools”.
	The Government said in their response:
	“We absolutely agree that preparing children for the world beyond education should be a key focus for all schools”.
	However, they gave no indication of how they will do that.
	I suggest a wider remit for secondary schools so that they provide opportunities for pupils. This is done in the best schools through team games, a cadet force, athletics, challenges, adventure and opportunities in drama, art, music and dancing, as well as debates and appropriate involvement in the running and discipline of the school—everywhere and always there are opportunities for belonging and to succeed. Not only secondary schools but youth movements and cadets should also participate in developing and helping tomorrow’s parents.
	I expect noble Lords will think that this will be very expensive and difficult to do. It will of course cost more, and it will need more teachers and teacher training, as well as money for facilities. But if noble Lords are worried about cost, I ask them to think about the cost of dysfunctional families today, recently estimated at more than £40 billion a year. We live today in a society where disadvantage is passed down from generation to generation. Our policy should be that that must stop.

Baroness Garden of Frognal: My Lords, I apologise for intervening, but the timing of this debate is beginning to drift. I remind noble Lords that when the clock reads “5” your time is up.

Lord Winston: My Lords, I will refer to two groups of experiments. First, in the 1960s, there was a classic neuroscientific experiment where newborn kittens were blindfolded for various lengths of time. After a short time of complete darkness, once the blindfold was removed, there were permanent changes in the visual cortex of the brain. That could not be fully corrected by any subsequent exposure to light. Although I completely agree with my noble friend Lord Giddens about the early years not being a special part, none the less, there are key experiences that we need during development which are not entirely ruled out by the arguments being made.
	Secondly, I point out that that is exactly why I take issue with the noble Lord, Lord Storey. I do not believe that it is as simple as he makes out. This is a very competitive area. I think that I can demonstrate that by the most amazing report done in 2001 by Lars Bygren of Sweden, who looked at a village in the far north of Sweden, near the Gulf of Bothnia. He showed that of males aged nine who were subjected to a good harvest during the period that he studied in the late 1800s and early 1900s, their paternal grandchildren, the sons, had a shorter longevity than any other members of the family. That is an extraordinary finding and suggests that there is programming. At the time, the report was not taken seriously, but since then a number of interesting epigenetic experiments have been carried out which show that many things that we inherit not directly through our DNA but through the way that the genes function make a massive difference.
	For example, Gregory Dunn, in Pennsylvania, has recently published a study in which he shows that an obese great-grandmother mouse passes on a trait through only her male children which causes their grandchildren, if they are female, to be obese. Obesity is a very
	complicated issue. This will apply to all sorts of areas of inheritance—it could well apply to cognition as well. The field of epigenetics is extremely confusing. That is why we need to be very careful not to make snap judgments about the complexity of early childhood learning. That is borne out by all sorts of other experiments which I do not have time to address.
	With regard to environment, I am surprised that the millennium cohort study has not been mentioned already; your Lordships will be aware of it, I am sure. It has looked at 19,000 children born since 2000-01. That study, funded by the ESRC, and a very good example of British cohort studies—one of the reasons why we want to support British research—has been a mine for all sorts of overseas investigators in France and elsewhere who have used those data. For example, it looked at parenting, childcare, school choice, behaviour, cognitive development and health. It looked at those children at nine months, three years, five years, seven years and nine years. It bears out some of the things that my noble friend Lord Giddens said. Although there may be serious evidence of undoubted changes in cognition in early years—certainly between three and five—by the age of seven, that can often be adjusted by other factors.

Lord Giddens: I point out that we are not a team and it is coincidental that we are sitting next to one another.

Lord Winston: I thought that in a time-limited debate the noble Lord would not interrupt me, but I forgive him as he is a noble friend.
	My point is that a whole range of claims are made by all sorts of authorities about maternal health and how it affects cognition, breastfeeding, socialisation, social recognition and play. Undoubtedly, when there is severe deprivation—for example, in Romania—there is clear evidence of massive changes. Nelson and his group at Harvard University have shown clearly that good fostering makes a massive difference when a child has been in institutional care for a long period but, sadly, most of those children never recover completely—certainly, in their ability to deal with emotion, stress, some aspects of cognition and so on.
	Although I argue that we certainly need to do more about early years learning, it is very important that successive Governments focus this work in the best possible way to have the key access to those most at risk. That is one reason why the Sure Start programme was a good start in trying to do that.

Baroness Walmsley: My Lords, I thank the noble Baroness, Lady Massey, for giving me this opportunity to speak about preventing the abuse and neglect of children. Scientific and social research have proved that the development of a baby during the first two to three years has an enormous effect on the personality, happiness and achievement of the adult, and thus on the whole of society. National and local government policy can and should be mobilised to ensure that all babies can have good, healthy physical and mental growth and develop
	resilience. These matters affect their social mobility and, consequently, are the very foundation of progress towards social justice.
	International experts have shown the effects of stress, violence, poor parental attachment, neglect and poverty on babies’ brains. We now know that during the first two years, new synapses are being added at a rate of more than a million per second and that the nature of these pathways is affected by the treatment that the child receives. We also know, without a shadow of a doubt, that the child’s brain can be damaged irrevocably by violence and maltreatment.
	Politicians have played their part, too, but there is one organisation that has played a greater part than any other in bringing these matters to the attention of government and in developing policies and strategies to address them. It is the WAVE Trust, of which I am honoured to be a patron, led by its founder and CEO George Hosking. WAVE began in 1995 when George realised that the levels of child abuse in this country had not reduced in 60 years and that the majority of the policies and the money spent were reactive, simply cleaning up the mess which was left in individuals and society. He realised that unless we develop effective preventive strategies we will never be able to improve the situation, so he began researching worldwide for strategies that worked. One of the most outstanding was the family nurse partnership in the USA, and George managed to persuade the Blair Labour Government to start one up here. It has since been expanded by the coalition Government.
	It is vital that we work with young mothers who are at risk in order to ensure the physical and mental health of their babies. Despite its success, however, the FNP deals with only the tip of the iceberg and is expensive, so we need other strategies to help more parents who are struggling to do the best for their babies. WAVE’s report, Conception to Age 2—The Age of Opportunity, sets out a blueprint for local authorities. It has been widely used in the UK and recommended by UNICEF for use by countries across the world. WAVE is now leading a campaign to reduce child abuse and neglect by 70% by 2030. Responding to the challenge of providing hard evidence of how results can be achieved cost effectively during the normal life of a Government, it designed the Pioneer Communities project to test the effect of a comprehensive approach to preventing harm to children before it happens. The aim is to do this in six communities in the UK between this year and 2020. A pilot in four small areas is being supported by a £15 million grant from the Treasury. I am confident that the project will prove the case for prevention as a cost-effective approach to individual child well-being and social justice but it needs more financial support. We need a general national shift to primary prevention, not just a test in four small areas.
	WAVE has also led a consortium of organisations which helped the Scottish Government to improve their Children and Young People (Scotland) Act to deliver that Government’s aims. One of the ways that it has done this is through the Scottish Early Years Collaborative, which was mentioned by the noble Baroness, Lady Massey. This could be done on a
	regional basis in England. Will the Government consider this collaborative approach which has been so beneficial in Scotland?
	Finally, the WHO recently called for a public health prevention approach: specifically, a national action plan to reduce child maltreatment by 20% by 2020. Last October, Luciana Berger MP asked a Written Question of the DfE asking if it would respond positively to this. The Minister, Edward Timpson answered:
	“Responsibility for action to tackle child maltreatment and respond to the needs of vulnerable children rests primarily with local government … health services and the police … co-ordinated by local safeguarding children boards”.
	I fear that I find this answer extremely disappointing. It smacks of passing the buck. We need a nationally co-ordinated primary prevention plan, supported by the Government. Can the Minister do better than his colleague in another place? The evidence is there, the experts have spoken and the financial case is currently being made. It is time that this country was a leader in this matter, not a follower, and we could start by introducing a complete ban on hitting children and by introducing the mandatory reporting of child abuse.

Lord Bhatia: My Lords, I strongly support the noble Baroness, Lady Massey, in raising this serious issue, which is causing harm to the most vulnerable children in our society. I have been involved in early childhood education for over 50 years in east Africa, from where I come, in the United Kingdom and in Michigan in the USA.
	I was a board member of one of the most eminent early childhood foundations, the HighScope Educational Research Foundation in Michigan. HighScope’s Perry preschool research study examined the lives of 123 children born in poverty and at high risk of failing in school. The study found that adults at age 40 who had the preschool programme had higher earnings, were more likely to hold a job, had committed fewer crimes and were more likely to have graduated from high school than adults who did not have preschool education. It was estimated that when the US Government spent $1 on preschool education, it saved $7 in the long run as it cost more to deal with the crime and delinquency of the children who did not receive preschool education.
	In a report that I read a few years ago, I found the following information:
	“A wealth of evidence shows that education is a key determinant of life chances. As well as being a right in itself”,
	education allows,
	“individuals to develop the skills, capacity and confidence to secure other rights and economic opportunities”.
	We need to constantly remember and remind ourselves that education starts at the age of two, which is why early years education, free for all, is an imperative. By the time the child reaches school age, most key brain wiring, language ability and cognitive foundations have been set in place. The early years are critical in the formation of intelligence, personality, social behaviour and physical development.
	Investment in the early years offers outstanding returns in both human and financial terms. If children become confident and enthusiastic for learning early on in life, they are more likely to be better students. Children who get a good start do better in school, are healthier and function better as adults. Recent studies, including those by the Nobel laureate James Heckman, have shown that investment in childhood education is more efficient and cost effective than remedial programmes for adults. A 2007 UNESCO paper suggests that one of the compelling arguments for investment in early childhood education is that the failure to do so perpetuates social and economic disparity and the waste of social and human potential.
	There is a business case, as well as an educational case, for the Government making early years education free and mandatory. It is sad to see that early years education provision suffers every time there are economic crises, which ends up hitting the most vulnerable children and their families.
	Will the Minister tell the House whether free preschool education for children of two to four years can be made available, with trained teachers and facilities, over the next five years? What would be the estimated cost of such a five-year programme? Would the estimated cost be ring-fenced in the national budget?

Lord Farmer: My Lords, I also thank the noble Baroness, Lady Massey, for bringing this extremely important subject to our attention by securing this debate.
	Children in the earliest years of life are so vulnerable and so dependent on their parents that our focus has to be on strengthening families. Giving a child the best possible chance to avoid succumbing to an intergenerational cycle of disadvantage very often gives both the mother and the father a vital second chance to turn their lives around. They are frequently the product of a broken, fatherless or dysfunctional family themselves.
	Too often, fathers are unjustifiably ruled out of the picture and considered to be surplus to requirement, yet they can make a significant contribution to children’s development of identity and self-esteem and can bring vital material and less tangible resources into the family. When fathers play with, read to, and help care for their children, the children have fewer behavioural problems, both in the early school years and in adolescence, and have higher IQs at age three than children from otherwise similar social backgrounds whose fathers are not involved. The public understands this: a recent YouGov poll found that 95% of adults believe that fathers are important to a child’s well-being. Yet around a million children today have no meaningful contact with their fathers.
	The section in the Welfare Reform Act 2009 which made fathers’ inclusion on birth certificates compulsory unless grounds for exemption were met was never brought into force, but I urge the Government to do so. If fathers fail to register on the birth certificate, that predicts less involvement and low or non-payment of child maintenance.
	Early years provision, particularly based in Sure Start children’s centres, has a vital role to play by drawing in fathers. Sure Start has evolved greatly from its beginnings, but it needs to keep on doing so. Various organisations such as the Centre for Social Justice, 4Children and others are pressing all the political parties to make the development of family hubs, particularly out of existing children’s centres, a manifesto promise. What would those family hubs do? They would be local “nerve centres”, co-ordinating all family-related support, including universal and specialist services, to help both parents.
	Given the very high levels of family breakdown in this country, Sure Start family hubs would include couple relationship support and education as part of their core offer to families before, during and after separation. Local health commissioners would ensure that all ante and post-natal services are co-located within or co-ordinated from family hubs. Father engagement would be part of family hubs’ reformed core purpose and would be included in Ofsted and Care Quality Commission inspections and local authorities’ payment by results frameworks. All birth registrations would take place within family hubs; if new parents were able to register births in these family-focused settings they would see from the outset the help that is available.
	Concerns about the prevalence of domestic abuse are often raised to argue against making efforts to involve fathers. Children’s safety is obviously of paramount concern, so we urgently need more effective projects which work with male perpetrators of domestic abuse where they are genuinely desperate to change. I am not minimising perpetrators’ responsibility for harm inflicted, but we have to recognise that, even if they are absent, fathers still exist in the mind of the child and can influence little ones’ behaviour, self-worth and sense of identity.
	I support the right reverend Prelate’s enthusiasm for “Healthy Relationships: Healthy Baby”, a project supported by the Stefanou Foundation. In the pilots in Westminster and Stevenage, both parents receive the therapeutic help they need, whether they are the abuser or the abused, to stop perpetrating and overcome the impact of abuse and to address difficulties arising from their own childhoods. Crucially, and with safety as the overriding consideration, they are helped to co-parent the baby and other children, even if they decide not to remain together as a couple. Getting to the roots of why parents are unable to provide the consistent love upon which their children’s well-being is so dependent has to be prioritised.
	We are, as a society, never going to reverse the tide of family breakdown and dysfunction that tends to affect children’s life chances so gravely unless we help parents address the drivers of their own disadvantage. This requires difficult and careful work that draws in expertise and funding from the public, private and social sectors, but also community goodwill. Behind very many grass-roots organisations is a well of resource and friendship based, perhaps, in a local church or other faith community. This is a classic area in which the welfare society has to stand four-square alongside the welfare state.

Baroness Warwick of Undercliffe: My Lords, I am grateful to my noble friend Lady Massey for creating the opportunity to debate what has become a perennially important issue.
	We are by now familiar with the research showing that, by 22 months, a bright child from a disadvantaged background begins to be overtaken in key abilities by a less bright but privileged child. We are told that a child’s development score at 22 months is an accurate predictor of educational outcomes at age 26, yet still the public debate about life chances and social mobility seems to focus on 18 year-olds and what university they should go to rather than on whether our under-fours are receiving the best possible early years education to give them the opportunities in life that they deserve.
	Graham Allen MP argues passionately for a shift from our late reaction culture to one of early intervention. His 2011 report, Early Intervention:Smart Investment, Massive Savings, is persuasive that early intervention has the power to,
	“forestall many persistent social problems and end their transmission from one generation to the next”.
	His views and findings are supported by many others working in the field.
	The previous Labour Government had an impressive record of investment in preventive policies targeted at children, families and disadvantaged communities. The coalition Government have pulled back on many of those reforms, but they have sustained a commitment to early intervention, particularly through the work of voluntary organisations and the private sector—and here I should declare an interest, as my sister is an early years professional and has two nurseries in Nottingham. There is a clear consensus that early intervention is needed to ensure that all our children get the best possible start in life. We know that high-quality early education is one of the most important determinants of every child’s life chances.
	The Government’s child poverty strategy made a welcome commitment to 15 hours of free childcare for all three and four year-olds, and for two year-olds from low-income families. The introduction of an early years pupil premium to help three and four year-olds from the most disadvantaged backgrounds from April this year is also welcome, but it is still considerably below the help given through the older children’s pupil premium. The National Day Nurseries Association independent research for the Pre-school Learning Alliance showed that 70% of local authorities have never updated costs since the introduction of the funding formula, and that providers are losing an average £900 per child per 15-hour nursery place per year, making many unsustainable and pushing up the fees that parents have to pay for extra hours of childcare. Given the coalition’s avowed commitment to high-quality early years education, will the Minister commit to a review of the level of funding at least for two year-olds if not for under-fives?
	The Family and Childcare Trust believes that, while the introduction of universal credit and tax-free childcare gives welcome extra support with childcare costs, there will be at least 335,000 families who may miss out on this vital support because of the complexity and overlap
	between the two systems. We know that those at the most risk of poverty are the least likely to take up their entitlement to free early learning and childcare places. The trust argues that the Government need to review childcare funding to simplify the system for parents. Can the Minister give any assurance that this will be considered?
	Like my noble friend Lord Sawyer, I am also concerned about how we ensure the quality of this provision, and particularly high-quality staff. Low wages and the lack of career structure among nursery staff is an ongoing concern and will not change at all if provision is underfunded.
	I have just one last point about the importance of early years education for a particularly disadvantaged group, children in care. A 2012 report from the APPG on Looked After Children and Care Leavers, Education Matters in Care, noted that despite the best efforts of social services, schools, carers and government, looked-after children remained,
	“disproportionately destined to a life of academic underachievement”.
	Evidence to the APPG inquiry showed that interventions in the early years can have a tremendous and long-lasting impact on the future outcomes of children in care, particularly in relation to their education. I should add that research has also shown that early intervention before the age of four can be critical for children with disabilities where language is impaired or for those with autism, attention deficit hyperactivity disorder or dyslexia.
	Finally, I do not underestimate the complexity of the task. I endorse what the right reverend Prelate the Bishop of St Albans said about whole-system change. All agencies, local authorities, health and early years professionals, schools and parents need to work together if success is to be sustained. But in all this early years education is crucial to our attempts to improve the later life chances of younger children. Early intervention and its funding—sustainable funding—must become a key priority if we are to transform both the economic and the social potential of future generations.

Lord Ramsbotham: My Lords, like other noble Lords, I pay tribute to the noble Baroness, Lady Massey, and thank her for obtaining the debate. I also pay tribute to her for the informed, determined and far-sighted way in which she chairs the all-party children group. I echo the noble Lord, Lord Freeman, in paying tribute to Heather Evennett for her excellent Library Note. Finally, I pay tribute to the Minister who, ever since he has taken up his post, has made himself available to those of us who wish to discuss developments with him. I am particularly grateful for the provision of education, health and care plans for those in young offender institutions, which I know he is responsible for.
	I am very glad that the noble Lord, Lord Freeman, mentioned SkillForce, with which I have been associated ever since it began as a project in the MoD. While observing the children looked after by SkillForce, and during my time as Chief Inspector of Prisons, I began to wonder how the children who appeared in the
	criminal justice system had got there, and what could be done to prevent them entering it. That led me on to the two hobby-horses which I intend to ride for the remainder of my contribution.
	First, communication skills were referred to persuasively by my noble friend Lord Sutherland. I discovered that an awful lot of people in young offender institutions were simply unable to communicate and, of course, if they failed to communicate, you did not know what was wrong with them. By trialling the use of speech and language therapists in those institutions, we discovered that a great deal could be done. However, that in turn led to the conclusion that if this process had been started far earlier in these young people’s lives, they would not face the prospect of entering the criminal justice system at the age of 15.
	I chair the All-Party Group on Speech and Language Difficulties, which published a report on the link between speech, language and communication needs and social deprivation, which is the subject of this debate. Some of our conclusions have already been referred to in the debate—for example, a talented child from a poor background will be overtaken by a less talented child from a privileged background unless something is done to identify, nurture and develop their talents. We strongly recommended that every child’s communication needs should be assessed before the age of two. Indeed, that is happening in some parts of the country. It is being done by health visitors who are trained by speech, language and communication therapists. However, as the noble Baroness, Lady Massey, said, what is needed is co-ordination so that this happens across the country. Good practice needs to be identified and become common practice everywhere. As the noble Lord, Lord Winston, mentioned, people change and therefore an assessment is needed not just at the age of two; rather, a programme of assessments is needed throughout these young people’s childhoods because their circumstances and conditions will change.
	The second thing I want to say links up with what the noble Baroness, Lady Walmsley, said about the adolescent brain. I have been fascinated by the question of nutrition, and declare an interest as the vice-chairman of the Institute for Food, Brain and Behaviour. We have done work in schools and prisons that found that correct nutrition leads to a reduction in bad behaviour. More than that, Professor Michael Crawford has carried out a great deal of work on the importance of nutrition on the unborn. If I have one request to the Minister, it is for education on nutrition, particularly for girls, to be included in schools and young offender and other institutions so that they may prevent some of the problems that we have been talking about being developed by the as yet unborn.

Lord Touhig: My Lords, my noble friend Lady Massey is to be congratulated on securing this debate, and she has most powerfully set out her case highlighting the range of interventions that would help in early years. I agree with much of what she has said and share her ambitions, although I come to this issue from a different point of view. This is because, in my experience, the common factor that has influenced
	and failed so many people today is the lack of a role model, support, guidance and someone going that extra mile during their early years.
	A year or so before I retired from the Commons, I visited a village school in my constituency and the headmaster said to me, “Do you know, Don, when I came here to this school no one expected anything from me because no one in this village has been to university? Not because they are dull or stupid but simply because they never had the opportunity”. He said that he had had a conversation with a mother a week previously, and said to her, “Work with me. Your son is going to university”. She said, “University? You’re off your head. That’s not for the likes of us”. This story illustrates what I call the poverty of ambition—“College and university is not for the likes of us”. It is to our shame this view is widespread, especially in the south Wales valleys where I come from.
	That was not always the case. I grew up in a small mining village called Abersychan. Education there was seen as a pathway out of poverty. People consumed learning and the opportunities to learn as if their lives depended on it and, if they were miners trying to get out of the pit, their lives would certainly depend on their success in learning. Education and learning were breathed as if they were oxygen. What the state or the county council failed to provide, the miners’ welfare at the top of High Street certainly provided. The Abersychan miners’ welfare was not just a place to have a game of billiards or a Friday dance, it was a library—newspapers were there. It was the centre of debate and argument; all sorts of societies met within its walls, and there were classes on every subject one could imagine. Most of the students attending the classes were miners looking to education to give them a better life—a chance to get out of the pit. There was certainly no poverty of ambition among these lads. On top of that—this might not be seen as the measure of success or achievement by today’s standards—five lads from the small village of Abersychan got to the House of Commons. Two even managed to get into your Lordships’ House. It is important to bear in mind that such effort is crucial.
	Now, not everyone wants to, or should, go to college or university, but everyone should have the best possible chance. Ambition should not be seen as a sin. Social mobility is not something that should be shunned or despised. Perhaps those of us like me who are moving on a little in years and have seen many great changes in our lives should be at the forefront of encouraging those younger to reach out and achieve, and be ambitious, bold and confident. We have to be role models drawing on our varied experiences and backgrounds. We can do all the things that noble Lords have spoken of in this debate, but one thing we must make sure that we do is have an open system of education in this country that continues throughout it.
	Just because we close most of our schools at 4 pm from Monday to Friday and entirely at weekends, and thus deny the public access to wonderful facilities that they public have spent millions of pounds providing, it does not mean that we have to shut down education at 16, 18 or 20-plus. I had a constituent living in the village of Markham who got a university degree at 82. When I called on him, he set up a new challenge:
	“Parlez-vous Français?” he said. He had started to learn French. These opportunities have to be grasped. If I had one opportunity to do something positive to help the early years, I would start with the parents and grandparents, making sure that they were the role models and pushed ahead to give those following them a good chance.
	Almost 20 years ago, I came across an extraordinary statistic and was shaken by it. In the United States, 80% of people in work have been back in a learning situation or classroom since leaving school. The figure was 56% in Germany and Japan, and 30% in the UK. That is the measure of how far we have to go. We have to invest in upskilling and training our people. That is the best way to ensure that young people, in their early years in particular, have role models on whom they can focus and who can say that they can achieve these things, too. This is the best medicine that can cure the sickness of poverty of ambition. Invest in upskilling and training our people to ensure that they have opportunities to use the liberation that education and learning can bring to their lives. Will this make a difference for young people? I bet it will. I have never been more certain of anything in my life.

Baroness Tyler of Enfield: My Lords, I, too, add my congratulations to the noble Baroness, Lady Massey.
	As many other noble Lords have said, action to promote social mobility must start early. The gap between disadvantaged and more advantaged children emerges by the age of three and, as the work of the Nobel prize-winning economist James Heckman demonstrates, the earlier the intervention, the greater the effect will be in the long term. Indeed, I was pleased to hear the right reverend Prelate the Bishop of St Albans quote the Seven Key Truths report of the All-Party Parliamentary Group on Social Mobility, which I have the honour to chair. It clearly indicated:
	“The point of greatest leverage for social mobility is what happens between ages 0 and 3, primarily in the home”.
	The link between early intervention and social mobility is well established. We have the evidence by the bucketload. Many noble Lords will be familiar with the effective preschool, primary and secondary education study, which stated that children who attended preschool education performed better in their GCSEs and were more likely to be on track for a university degree—with all the attendant benefits in terms of lifetime earnings. These effects are even stronger for children of parents with low qualifications, indicating that early education provision is a key intervention to help disadvantaged children get a much-needed leg up.
	The October 2014 State of the Nation report from the Social Mobility and Child Poverty Commission recently re-emphasised the link, stating:
	“The early years matter profoundly to child poverty and social mobility. It is here that children learn basic skills such as language and communication, which are the foundations of their future learning”.
	That report noted that poor children are nine months behind those from more advantaged backgrounds at age three, have smaller vocabularies and are slower to
	learn new words. That, of course, is why various language development programmes aimed at under-threes—such as the Born to Learn programme, which works with parents and toddlers identified by health visitors as being at risk—are so valuable.
	I, too, have the privilege to be a member of the Select Committee on Affordable Childcare. From the mass of evidence we have received, one particular lesson stands out. Yes, early education can be a powerful tool in enhancing social mobility, but only if we deliver it effectively. In short, early education can have the most positive benefits only if it is of high quality. It is ironic that disadvantaged children, who have the most to gain from access to quality early education, currently often have the worst access to such provision. This is where we should be focusing a lot of our attention, and I hope that it is an area where the Select Committee can have powerful things to say when we report shortly.
	Having highlighted some of the pressing concerns, I want to make clear how much has been done in this Parliament to enable more children to benefit from high-quality early years education. I applaud the policies of this Government to expand the free early education entitlement to three and four year-olds and to extend it to 40% of the most disadvantaged two year-olds. Like others, I consider the recent introduction of an early years premium to be very much welcomed.
	However, what more could and should be done? First, it is clear that affordable and high-quality childcare and early education will feature predominantly in all parties’ manifestos. One could say that there may be a bidding war. I do not mind; it is a good thing that it is there. Secondly, I should like to see manifesto commitments to other things, such as the introduction of children and family hubs—the sort being developed by the charity for children which we have already heard about this morning. These are building on and extending existing children’s centres, and I, too, pay real tribute to the previous Government for introducing them. They bring together a broad range of local services, including health, childcare and social care, into a single place in a non-stigmatising way, and they provide a really excellent model of cost-effective joint working.
	Finally, we need to see action to raise the quality of the early education workforce. As Cathy Nutbrown wrote in her review, not much matters more for the quality of early years education than the quality of the staff who provide it. I should like to see more action taken in that area.
	Having made those points, I want to go back to where I started. Promoting good child development has to start at home. Research shows that parenting is the single strongest factor in shaping children’s development. We also know that good parenting has a particularly large impact on character and resilience. Good parenting practices can be taught and promoted through relatively simple interventions. That is one reason why the all-party groups on both social mobility and parents and families are about to embark on a short joint inquiry into some of the most effective non-stigmatising approaches to parenting support. The inquiry will report in March and I look forward to reporting its conclusions to your Lordships’ House.

Baroness Finlay of Llandaff: My Lords, like others, I congratulate the noble Baroness, Lady Massey of Darwen, on having secured this debate and on attracting a large number of speakers.
	I want to focus on the development of the brain. Without our brains, we cannot learn, we cannot learn language and we cannot interact. If in the next generation we do not ensure that brains are developed property, we will not break the cycle of maltreatment and failure within the social environment and every other environment in society.
	It is worth noting that 90% of brain size has been acquired by the age of three, so the focus on the first 1,001 days—that is, from conception to the age of two—which has already been alluded to by other speakers, is critical. The Wave Trust has done a lot to raise awareness and to pull together the evidence in this area. The long-lasting effects of maltreatment are in the physical, socioemotional, cognitive and behavioural domains.
	The consequences and costs of such maltreatment are phenomenal. As has already been said, managing it costs about £15 billion a year. As well as the physical and mental suffering of the individual and the damage to educational prospects, there are also high levels of aggression, which damages others in society. It is of note that 68% of those in the prison population have been abused or neglected in childhood. The Christie commission in Scotland estimated that 40% of public spending is necessary only because of our failure to intervene early enough. We are accumulating huge future expenditure by not looking at this very important area.
	It is also worth noting that about one in five children is maltreated, the peak time being in the first year of life. Sixty-two per cent of those entering care in 2013 had been subject to abuse and neglect. In March of that year, more than 68,000 children were in care, so it is a very big problem. Five per cent of children have a diagnosable mental health condition, and 15% to 20% of behavioural problems are severe enough to cause concern. This is costing about a quarter of a million pounds per child. Interventions on parenting programmes that cover the period from birth onwards cost less than £2,000 per case. The difference in cost is phenomenal, and it seems almost madness that we have not addressed this issue on economic terms alone.
	About 1 million children in the UK are suffering the long-term effects of maltreatment, with all kinds of behavioural disorders, but it is worth noting that the greatest predictor of prenatal depression is that the mother was herself abused. She has a tenfold likelihood of becoming an abuser. A third of abuse occurs when under the influence of alcohol. I urge the Government to get to grips with alcohol policy, particularly pricing and so on, because it may have a huge effect. In families with a history of domestic violence, there is a 23 times greater likelihood of abuse being perpetrated against children under the age of five. I stress the importance of domestic violence as a contributory factor.
	It is worth considering briefly why this happens. As the brain develops, areas that are stimulated develop more. Those that do not receive stimulation, as the noble Lord, Lord Winston, has already pointed out, do not develop to the same extent. Therefore, even in the womb the child subject to stress develops a stress reaction, and the brain develops the ability to respond to stress. Children who have not experienced a calm environment do not develop the ability to have empathy and they cannot be expected to feel remorse for later hurting or killing somebody, because that part of their brain is not properly developed. Nor can they develop communication skills. Therefore, the child subject to hyperarousal all through those very early days and weeks will develop a state of permanent hyperarousal and response within the brain. That plasticity of the brain carries on throughout the child’s development until the age of 16, so the other educational interventions referred to by noble Lords all help in developing the areas of the brain that have not developed well.
	In my last seconds I would just stress that cutting back on mental health services in the perinatal period may be the most serious adverse disinvestment that the NHS is currently undertaking.

Baroness McIntosh of Hudnall: My Lords, my noble friend has stimulated an excellent debate, for which we should all congratulate her. Coming nearly at the end of the speakers list, the temptation is to spend your time saying how much you agree with everybody else. I would like to do that but I shall not, although I would like to say that I was particularly struck by the speech of the noble Lord, Lord Sutherland, which I hope I shall be able to reflect on by implication in some of what I say. The House will not be surprised to know that I want to talk about the arts in early years provision, but I am afraid that I am going to start on a slightly sour note, which I hope the House will forgive.
	On 10 November last year, the Secretary of State for Education made a speech at the launch of the Your Life campaign in which she said the following:
	“Even a decade ago, young people were told that maths and the sciences were simply the subjects you took if you wanted to go into a mathematical or scientific career, if you wanted to be a doctor, or a pharmacist, or an engineer”.
	I am not absolutely sure that that is true but that is what she said. She went on:
	“But if you wanted to do something different, or even if you didn’t know what you wanted to do, and let’s be honest—it takes a pretty confidence 16-year-old to have their whole life mapped out ahead of them—then the arts and humanities were what you chose. Because they were useful for all kinds of jobs”.
	So far, so good, you might think, but then she went on:
	“Of course now we know that couldn’t be further from the truth, that the subjects that keep young people’s options open and unlock doors to all sorts of careers are the STEM subjects: science, technology, engineering and maths”.
	Those remarks are deeply disappointing and wrong on so many counts and in ways which go directly to the heart of this debate. As we know and as we have heard, children are capable, if they are encouraged, supported and educated thoughtfully from early on, of learning many different things in many different
	ways. The flexibility of mind that comes from a broadly based education is exactly what employers look for in all fields. I thought that we had left the idea of two cultures far behind but apparently not. It is profoundly unhelpful for such simplistic distinctions to be made.
	Many of your Lordships—perhaps most in this House—are parents. Some of us are lucky enough also to be grandparents. Over the past few weeks lots of us will have had the pleasure, albeit occasionally a mixed one, of taking young children to arts events and/or of just sitting on the sofa with them reading, or watching, for example, “Frozen”—a cultural reference for those of your Lordships who have very young daughters or granddaughters in particular. We will have observed their joy and their absorption, and the way in which that kind of experience moves them on. They find new language, new questions to ask and new ways of thinking about the world—even the very little ones do. However, as we have heard, not all children are lucky enough to get this kind of stimulation as a natural part of their family lives, which is why it is so important that we understand and value how it can be incorporated into other areas, particularly school.
	I want to mention briefly one organisation which is contributing magnificently to this important work. Artis Education has been in business for 10 years. I stress the word business for it is not a charity. Schools have to pay for its services, which they do. Nearly all its schools are in the maintained sector. I was until recently a director and the noble Lord, Lord Bichard, who is not able to be in his place today, was involved in setting it up. Artis trains specialists from performance backgrounds to deliver inspirational cultural enrichment which can be, and often is, directly related to national curriculum requirements. Its programmes are of particular benefit in raising levels of confidence and self-esteem in young children, and are recognised by head teachers and other educationalists for contributing to increased concentration, improved behaviour and overall eagerness to learn.
	I recommend the Artis website to your Lordships and especially to the noble Lord the Minister. It is an inspiring read. On it you will find, for example, a wonderful blog from the noble Lord, Lord Bichard, entitled “I am not an artist”, which gives 10 excellent, evidence-based reasons why arts education is so important for young children, for society and for the economy. You will also find details of Artis’s 10 tools for transforming the new science curriculum, which set out how teachers can use arts-based techniques to address science topics. Artis says:
	“This sense of wonder and fascination with the surrounding world is as important in performing arts as it is in science, and the two disciplines have many points in common”.
	Well, who knew? How very true and how very obvious, but not, apparently, to the Secretary of State. Perhaps her noble friend the Minister will put her straight after this debate.

Lord Ouseley: My Lords, I thank the noble Baroness, Lady Massey, for introducing this debate and for the immense work that she has done over
	many decades for young people and children. It has been inspirational to all of us who have known the noble Baroness and her work for many years. I also thank all those who work with children. Many people across the country do tremendous work for our young people, particularly in their early years. In acknowledging that, it is important to understand the importance of that to the society in which we live.
	Listening to this debate, I have been fascinated. I almost think that we are talking about children who are the same and are looking for the same outcomes. Although we have had a wide range of expert, fascinating and very important contributions, the most important contribution that links to what I want to say was made by the noble Lord, Lord Sutherland, who talked about language and communication in the broadest sense. The spoken word is so important in influencing attitudes and behaviour. I would say that if, as has been said in this debate, the predictor in the early years leads to the outcome in later years, when one thinks of someone like Ched Evans and what he is facing now, I should like to know what his early years were like. Upbringing in the early years may help us to understand how men behave towards women later in life.
	I want to talk about what we are educating our children for, what the interventions are about and the society in which we live. When we talk about language and communication, in areas such as London where in parts we have 300 languages being spoken, the spoken word is very important in how we influence very fertile minds. Creating a future in which every child really matters, has a realistic prospect of genuine social mobility and well-being, achieves their full potential, and is equipped for a diverse, fair, less prejudiced and hateful society, is the outcome for which we are looking. That is the context in which we need to consider these interventions.
	For me, three strands are interlinked. One is the role of the state and everything that has been spoken about in terms of health, education, housing and the environment, and how we achieve free or affordable childcare and support for the involvement and the work of voluntary organisations working with children and families. Support for families is very important and I offer my congratulations to the Government on the programme that they support for troubled families, led by Louise Casey, and the way in which it brings all those contributors together to help families break through the cycle of deprivation.
	My primary points are about how we face up to the dangers of bias and prejudice in the home, in early years settings and in the wider society; how we are preparing our children to flourish in a diverse, fair and prejudice-free society; how we identify the extent of prejudice, bias and discrimination in our society and how it affects attitudes at all ages; and how we understand that early on children are adversely affected and influenced by biased opinions, views and attitudes. We know that the only time any of us is free of bias and prejudice is when we are born. Bias and prejudice comes from our parents, family members, friends, nursery and care settings, the media and wider society. All these things must be addressed as part of early interventions in order that in later life we have adults
	who can contribute to bringing about a fair and just society from which children will benefit in their early years.
	All children matter in this context, not just those from deprived backgrounds. We all carry those biases which lead to discrimination. The early years are the most intensive period of learning. We want to influence attitudes most profoundly in the home and in the early years settings to make sure that our children have a beginning that, as far as possible, is influenced by positive attitudes. The opportunity to learn in settings with children from different backgrounds is the opportunity to learn about each other, with each other and from each other, and about oneself. Bearing in mind that I am now at the five-minute point, I will sit down.

Baroness Jones of Whitchurch: My Lords, I am grateful to my noble friend Lady Massey for tabling this debate and I add my tribute to her consistent record of championing children’s issues in this House. The issues that she and other noble Lords have raised encompass a wide sweep of social policy. We have heard about some impressive initiatives that are taking place on this issue—but that does not take away from the scale of the challenge that remains ahead.
	As the latest Social Mobility and Child Poverty Commission report says, Britain is on the brink of becoming a permanently divided nation, with rising living standards bypassing the poorest in society. It concludes that there is little chance of the Government meeting the current statutory target of eradicating child poverty by 2020, which has clear and damaging consequences. As we have heard in this debate, what starts as a scandal of children being born into poverty, holds them back for a lifetime. Their education will suffer compared to their peers; they will end up in less well paid jobs; they will live in more overcrowded housing; and their health will suffer. Their children will be born into poverty and the cycle will begin again.
	Sadly, what is missing is a coherent and ambitious government plan to break this cycle. The truth is that different departments are pulling in different directions, with disadvantaged children losing out. For example, a recent report of the Children’s Commissioner into the tax and social security measures of this Government since 2010 shows that families with children lost out and that the greatest losses were for the poorest 10% of families. It also shows that the most vulnerable children, such as those with a disability or being raised in a single-parent family, lose out the most. This is the result of a deliberate government fiscal policy.
	Similarly, the Government’s independent adviser on health reports that the impact of this poverty can already be seen among five year-olds, with those on free school meals lagging behind their peers in being “school ready”. This includes being able to listen to stories, pay attention, use the toilet, dress themselves, and begin to read, write and do sums. As we know, this educational attainment gap widens as these children progress through schools. His report concludes that this disadvantage will be accompanied by poorer health,
	higher teenage pregnancy, higher numbers out of education, employment and training, and finally lower life expectancy.
	Breaking this destructive cycle is not only a challenge for one department or one term of government: it requires a different mindset with a longer-term vision about the kind of society we would like to see in the 21st century. Certainly on these Benches we would argue for a fairer, more equal society where those deep divisions were addressed. We took this approach in the last Government and would do so again.
	We would also hope to create a wider political consensus on the measures needed. This is why I join with my noble friends Lady Massey and Lady Warwick in paying particular tribute to my honourable friend Graham Allen, who has not only championed the case for early intervention as a solution to breaking the cycle but has managed to win support from across the political spectrum for his approach.
	Crucial to Graham Allen’s approach is a belief that we need evidence-based solutions. We need to collate the very best research about which interventions work, share this best practice and refresh our learning as we progress. Inherent in this approach is the understanding that this is a long game and that policy initiatives cannot be instantly evaluated. This point was eloquently made by the right reverend Prelate the Bishop of St Albans and my noble friends Lord Giddens and Lord Winston. For us, of course, as policymakers, this is incredibly frustrating as we like instant solutions. Nevertheless, we have to face the fact that it is true.
	I pay tribute to the Government for funding the Early Intervention Foundation to do just that. It is not as much as we would like but it is a start. I hope that the Minister will be able to confirm his continued support for this programme. After all, we all hope that we can prove the ultimate goal, which is that effective early intervention will not only improve the life chances of young children but will save the state money in the longer term.
	Arguably, when we talk about early intervention, we need to talk about the earliest intervention. To make a real difference we need to intervene while the child is still in the womb, or even before conception, to make sure that it is a planned birth. Young people, who may not have had strong role models of their own, need education and support to understand the social and emotional, as well as the practical, challenges of bringing up a child. I very much echo the comments of the noble Lords, Lord Sutherland and Lord Ramsbotham, about investing in speech and language therapy in early years as part of that important development.
	Research from Joseph Rowntree and others has confirmed the point—made by a number of noble Lords in this debate—that early interventions which focus on parenting skills are some of the most effective in improving the child’s educational outcomes and thereby their future employment prospects.
	This is exactly what the Sure Start programme introduced by the previous Government was intended to do, which is why it is so sad that David Cameron has reneged on his promise to protect the service. A recent local authority survey by 4Children showed
	that one-third of the remaining children’s centres are at risk of being shut down, on top of the 600 or so that have closed or merged since the coalition came to power. Conservative-run Swindon Council has this year cut the budget to children’s centres by £770,000, leading to the closure of seven out of the 12 centres, despite a promise to local parents that the service would be protected from further cutbacks This is not only a broken promise to families in Swindon but is incredibly short-sighted and leaves many of the city’s most vulnerable children without a place to go.
	This is why our approach will be to renew Sure Start by opening up the centres to other local family services, such as health and childcare, to maximise the use of buildings when money is tight. By co-locating family services in the centres we can create family hubs in localities which can focus on effective learning, provide help and outreach and become more responsive to the communities they serve. These family hubs are exactly those proposed by the noble Lord, Lord Farmer, and I pay tribute to his contribution. Perhaps when the Minister replies he can clarify what plans his Government have for revitalising the Sure Start network and give some reassurance to all those families who rely on the service currently or would want to do so in future.
	It was interesting to hear from a number of noble Lords who are members of the Affordable Childcare Select Committee, and we look forward to their report. We believe that our policy to expand free childcare for three and four year-olds from 15 to 25 hours a week for working families will help guarantee quality childcare in safe settings while avoiding the risk of driving up childcare prices for parents. This is in contrast to the Government’s childcare policies—some of which, of course, are welcome—which fail to address the fundamental problem of supply.
	There has been a reduction of more than 35,000 in early years places since the Government came to office, so it is not surprising that the cost of childcare for those who pay is continuing to ratchet up, to an extent that even the proposals in the Government’s Childcare Payments Act cannot hope to alleviate or match. Perhaps the Minister can explain what steps they are proposing to take to increase the supply of quality trained nursery nurses and quality places to meet this additional demand. Can they make a commitment to implement the Nutbrown recommendations to ensure that that quality and training is underpinned?
	Our approach is based on a holistic model that works with families and communities. Our mission is to reform public services, to shift from crisis intervention to early intervention. We believe that our intervention model will reduce inequality, boost social mobility and narrow the gap between the most vulnerable and the rest. I look forward to hearing whether the Minister is able to match our vision and provide a persuasive programme for tackling these issues in the future.

Lord Nash: My Lords, I thank the noble Baroness, Lady Massey, for securing this important debate, and all noble Lords for their speeches. The
	noble Baroness referred in her eloquent opening speech to the terrible state of relative social mobility in this country—or, rather, our dreadful social immobility—and to the importance of early intervention in that regard. At the end of this Parliament, as at the start, the coalition Government remain fully committed to breaking the cycle of deprivation, promoting social mobility and a more equal society.
	Central to this is the goal of ending child poverty in the UK by 2020 and reducing inequalities. Despite the challenging economic circumstances and fiscal restraint imposed on us by the state of the public finances that we inherited, we are making significant progress, with 300,000 fewer children living in relative poverty under this Government. The evidence is clear that work remains the best route out of poverty. We know that children are three times as likely to be in poverty if they live in a workless family. Therefore, at the centre of our child poverty strategy is a commitment to tackling worklessness, and it is clear that our reforms are making a real difference. Thanks to this Government’s jobs miracle, employment is up by nearly 1.75 million since 2010 and there are now nearly 400,000 fewer children in workless households. Both the number and the proportion of children in workless households are at the lowest levels on record.
	Through our structural reforms to welfare we are lifting people out of poverty, putting in the right incentives to get people into work and to make work pay. As for action before they reach the workplace, this Government’s commitment to improving educational outcomes has seen poorer children do better than ever at school. Since 2010 the proportion of children on free school meals getting five good GCSEs has increased by more than 20%, from 31% to 38%. These are substantial leaps in educational attainment which will make a real and lasting difference to children’s lives as they develop.
	Evidence strongly shows that good-quality early years provision, especially from age two upwards, has benefits for children’s all-round attainment and behaviour, particularly for disadvantaged children, and that these endure all the way through to GCSE and future earnings. Attending preschool has led to young people getting higher total GCSE scores and higher grades. They are more likely to achieve five or more good GCSEs. The benefits of going to a preschool translate into an extra 41 points, which is the difference between getting, for example, seven grade Bs versus seven grade Cs. In addition, the Institute for Fiscal Studies estimates that children who have attended preschool will be substantially financially better off over their lifetimes.
	We know that early education matters and we have already increased the free early education entitlement for all three and four year-olds to 15 hours as compared with 12.5 hours under the previous Government. However, we know that the poorest children are less likely to take part and benefit from early years education, and it remains a concern that children from poorer backgrounds continue to start school having achieved less than their richer peers. Our new entitlement to early education for around 40% of the most disadvantaged two year-olds aims to address this gap, and already more than 150,000 children are benefiting from this.
	We have supported the aim with an investment of £150 million. I have to say that when I first heard about this requirement for a massive increase in places, I thought that it was a very challenging delivery task, so I would like to congratulate both the sector and the officials in my department on managing this increase in provision. The has clearly been a great success, as has been acknowledged by many people, including Alan Milburn.
	The gap in participation and achievement between the poorest and others is also why we are encouraging more schools to offer nursery provision, either themselves or in partnership with others. Schools are trusted and convenient, particularly if an older sibling is already attending. Nurseries attached to primaries have higher-qualified staff, which has clearly been shown to improve outcomes, and this kind of provision can improve the transition from nursery to primary because it enables schools to get to know the families earlier.
	We are increasing accountability. From 2015, the reception baseline will be introduced, and from 2016 this will be used to hold schools to account for the progress from reception right through to key stage 2. The reception baseline will provide a snapshot of each child’s starting point in reception and means that the progress schools make with all children, including those from a low starting point, will be recognised. However, we cannot and will not be complacent. While the attainment gap is narrowing at the age of 11, data show that a persistent attainment gap of some 19 percentage points remains at the age of five between the poorest children and their better-off peers. Our reforms are intended to tackle that, and the early signs are good, but we must continue to apply every effort.
	As the noble Lords, Lord Ramsbotham, Lord Sutherland and Lord Ouseley, and the noble Baroness, Lady Jones, have said, language is extremely important. We know that particularly children from disadvantaged backgrounds can struggle with language and will hear literally millions fewer words during the course of their childhood than their more advantaged peers. Improving the assessment of children’s early language and communication is important. The healthy child programme review and the early years foundation stage progress check at around the age of two provide the means to do this. Through the early language development programme, more than 12,000 practitioners have been helped to support early language development. Moreover, we have reformed the early years curriculum to be more focused on literacy and our phonics programme has been a huge success.
	After 12 years of consistently rising prices, the costs of childcare in England have stabilised for the first time. Once inflation is taken into account, costs for some of the most popular types of childcare have actually fallen. This means that more parents are able to access affordable childcare and support their families. However, we are going further. We will provide up to 85% of childcare costs through universal credit. Tax-free childcare, which is being introduced this year, will be accessible to many more families than the current employer-supported childcare scheme, which is offered by only a minority of employers. Tax-free childcare will also be available to self-employed parents.
	The Government are also improving children’s outcomes through other key reforms, including additional funding for disadvantaged children through the early years pupil premium, which will help to close the gap between children from disadvantaged backgrounds and their peers. Today, my honourable friend the Parliamentary Under-Secretary of State for Children is announcing the names of seven local authorities that are implementing the new support this term, and which will be available throughout England from April.
	My noble friends Lord Storey and Lady Tyler and the noble Lord, Lord Sawyer, mentioned issues around the early education workforce. We know that the qualifications of the workforce directly impact on the quality of provision, and it is very pleasing to see that the proportion of staff in early years education with level 3 qualifications continues to increase, as does the proportion qualified to at least degree level. We also recognise that health is closely tied to achievement, and we are working with colleagues across government to ensure that children get effective and joined-up support. There is a significant body of evidence which demonstrates the importance of sensitive, attuned parenting for promoting secure attachment and bonding, especially during pregnancy and the early weeks following childbirth. The earliest experiences shape a baby’s brain development and have a lifelong impact on its mental and emotional health. This is a period of great opportunity, but also of great vulnerability. There is clear cross-party support for early intervention, and the Government have made significant progress in this area through strengthening the health visiting service, delivering the healthy child programme, launching the Early Intervention Foundation, and working with various stakeholders to ensure that all children have the best possible start in life.
	While there is widespread agreement that the activities which take place during the early years are very important, the challenge is working out precisely how to invest money most effectively, thus targeting the right children in the right way in order to get the best outcomes, as the noble Baroness, Lady Jones, mentioned. Stronger evidence is needed to help local authorities make the best funding decisions for the long term in order to complement the work of the Early Intervention Foundation and link closely to other activities such as the healthy child programme, the troubled families programme and family learning provision. That is why the Chancellor announced in the Autumn Statement a zero to two year-old early intervention pilot to be run jointly by the Department for Education and the Department of Health to prevent avoidable problems later in life. The Government will work with pilot local authorities to draw on the success of the troubled families programme, and I am grateful to the right reverend Prelate the Bishop of St Albans and the noble Lord, Lord Ouseley, for their kind words about its achievements.
	My noble friend Lady Walmsley mentioned the report, The 1001 Critical Days. This sets out the particular importance of perinatal and maternal mental health. The Department of Health is already working on a number of measures in this area. Furthermore, the evidence-based healthy child programme, the key universal public health service for improving the health
	and well-being of children, aims to prevent problems in child health and development and to contribute to a reduction in health inequalities. In November, the Department for Education and the Department of Health jointly published the findings of a year-long study of pilots run in 10 local authorities looking at ways to get health visitors and early education practitioners working closely together to give parents a coherent and useful assessment of their child’s development at the age of two. This should help to identify as early as possible any areas where a child needs additional support to get them on the right road to success. We expect health and education practitioners to work together to deliver integrated reviews from September this year. Both departments have also been working on the CANparent pilot, which was introduced to offer high-quality, stigma-free, universal parenting classes to enhance the skills and confidence of mothers and fathers, and ultimately to improve outcomes for families. Almost 3,000 parents in total have now taken part in the two CANparent trials across the four trial areas, and a new one-year trial is being set up.
	As the noble Lord, Lord Ramsbotham, the noble Baroness, Lady Finlay, and my noble friend Lady Walmsley all mentioned, domestic and child abuse are also important issues. In December, my right honourable friend the Home Secretary announced an intention to create a separate offence of domestic abuse. This demonstrates our commitment to tackling all forms of this terrible crime. Furthermore, we are providing nearly £1.4 million to support young victims of domestic abuse, and have supported health visitors to help them identify and respond to such abuse.
	As my noble friend Lord Farmer and the noble Baroness, Lady Massey, both mentioned, children’s centres have an important role in supporting families through accessing universal services and targeting those at risk of poor outcomes. The noble Baroness, Lady Jones, talked about the closure of Sure Start centres, but the important point to make is that an independent survey has shown that a record number of parents, more than 1 million, are now using children’s centres. The noble Baroness also asked about increasing provision from 15 to 25 hours. It is very important to have a balance between childcare and family provision. We understand that this has been costed at £800 million and would be funded by the bank levy—which I am told that the Labour Party has already pledged 11 times already. However, we believe that it will actually cost £1.6 billion, and providers tell us that they will struggle to provide this level of extra provision and maintain the quality without increasing costs, which means that the £1.6 billion is likely to increase. If people want more support, this can be provided through the working tax credit, the coming universal credit and tax-free childcare.
	The noble Baroness, Lady Massey, referred to a Scottish programme, which I will certainly look at. My noble friend Lord Freeman referred to SkillForce, of which he is chairman, as did the noble Lord, Lord Ramsbotham. I am well aware of this excellent organisation and the very good work that it does. This Government are very keen to engage ex-service personnel in schools through organisations such as SkillForce, Challenger Troop and Commando Joe’s, and we have
	an active programme of expanding cadet units in schools. My noble friend Lord Freeman asked whether we will get access to a Euro fund on youth unemployment. I will write to him about that. The right reverend Prelate the Bishop of St Albans and my noble friend Lady Tyler talked about the importance of family. Of course, it is a question of balance between childcare and the importance of children forming a close attachment with their parents, or at least with one parent.
	The noble Lord, Lord Giddens, made some extremely interesting points about relative social mobility, as did the noble Lord, Lord Winston, about epigenetics and the importance of continuing support throughout a child’s life. I agree entirely with those comments and can assure them that this Government, and this Minister in particular, are heavily focused on relative social mobility. Some 7% of children in this country go to private schools, and they get over 50% of the top jobs, while just under 5% go to grammar schools, and they get over 20% of the top jobs, which leaves the other 90% of students in this country getting, at best, between 20% and 30% of those jobs. That is why this Government have been so focused on improving the quality in particular of what we used to call comprehensive education. The noble Lord, Lord Giddens, referred to what he talked of as an underclass, and I would just mention the success of our troubled families programme in this regard.
	The noble Lord, Lord Northbourne, referred to schools having a wider offer of facilities and extra-curricular activities, including cadet programmes. He also talked about weekly boarding, something of which I am a great fan and which, when I finish this job, I intend to introduce at the secondary school I support. The noble Lord, Lord Farmer, made some very interesting points about fathers and absent fathers. I know from my work in schools the damaging effects suffered by so many children who have no male role models. This can be so damaging for both boys and girls, which again is why engagement with organisations such as SkillForce can be so important.
	The noble Baronesses, Lady Warwick and Lady Jones, talked about overall funding for early education. We have increased this from £2.6 billion last year to £2.9 billion this year. The Family and Childcare Trust costs survey in 2014 gave an average cost of £4.25 per hour for children aged two and over, which compares favourably with the government funding rate of £4.51 per hour, or £5.09 for two year-olds.
	The noble Lord, Lord Ramsbotham, made some interesting points about nutrition, which of course is so important in schools. Good schools focus on it heavily, and it is also about engaging with parents. Quite a lot of advice is available from the Department of Health for new parents on this but I will look at what more we can do in this area.
	The noble Lord, Lord Touhig, talked about poverty of ambition. When I was at university—I was only the second person from my school ever to go to university—it was with a lot of Welshmen from whom I learnt a great deal, including some interesting tactics on the rugby field. Sadly, the schools from which those young men came no longer send many, if any, children to that university. We need to turn this round.
	The noble Baroness, Lady McIntosh, talked about the importance of the arts. Pupils in this country, on average, take more than 11 GCSEs or equivalents, so there is plenty of scope up to 16 for a very balanced curriculum, with plenty of room for arts subjects. All children should have a broad, balanced and fully rounded education, and I shall certainly look at the website that she referred to. We need to encourage more pupils, particularly girls, to consider taking more STEM subjects.
	This Government are committed to tackling deprivation and promoting social mobility. We have introduced a number of key measures to tackle health inequalities, to support parenting and to provide high-quality early education to children from low-income families. We have a strong record of success: relative child poverty is at the lowest level for 30 years, there are 300,000 fewer children in relative poverty since the election and nearly 400,000 fewer grow up in workless families. At the same time, we have had a massive programme of improvements to the education system, particularly for less advantaged children. The quality of education is improving, with more children doing better at school. This is a record of which we can be proud. I again thank all noble Lords, particularly the noble Baroness, Lady Massey, for their contribution to this debate.

Baroness Massey of Darwen: My Lords, this has indeed been a splendid debate, as I thought it would be. I thank all noble Lords for their contributions, which have been well informed and based on research and experience. I also thank the Minister for his very thoughtful response. I may challenge some of his precepts but I thank him for his concerns. Surely all of us, whichever political party we belong to, want to see better and more confident parents, happy and active children, better citizens, and greater prosperity. I just want to comment on four or five points, as I cannot possibly comment on the whole debate,.
	First, we should beware the tips of icebergs. I will not sing the song from “Frozen” at this point—I think it is called “Let it Go”, which is what I am about to do. However, we should really get down to the grass roots and, as many noble Lords have said, co-ordinate agencies and initiatives to target children and families so that they do not get a mass of things coming at them without any co-ordination or without key workers. Neither we nor children come in pieces; therefore nor should services. That co-ordination needs leadership and vision. It also needs, as has been said, continuous intervention; this is not just about early intervention but about intervening along the whole children’s pathway. Children do not come either in age-related bits, so we need cohort studies to show how we are doing in a more protracted way.
	A lot has been said about the costs of not using early intervention as a tool. We should be dismayed by the costs, certainly of health and education issues. I hope that whichever Government—or Governments—comes into power in May, they will take this by the scruff of the neck and say, “We will co-ordinate services,
	we will provide leadership and vision, and we will get to grips with this issue of children’s achievements and performance”.
	Motion agreed.

Ebola
	 — 
	Question for Short Debate

Lord Fowler: To ask Her Majesty’s Government what lessons they have learnt from the recent Ebola outbreak in West Africa.

Lord Fowler: My Lords, I welcome the opportunity of this short debate. First, I would like to pay tribute to the brave people who have gone from other countries, very much including the United Kingdom, to help tackle the outbreak of Ebola in west Africa. Obviously, I am thinking of Pauline Cafferkey, being treated at the Royal Free Hospital in London, and we all very much pray for her recovery. But I also pay tribute to all the others from different occupations and disciplines who have gone to help, including the 70 volunteers from the National Health Service. They have put their own health at risk and we should remember that, among the 680 healthcare workers who have contracted Ebola since the first outbreak of the disease, no fewer than 400 have died. These men and women have come from other countries in Africa and from around the world and have paid a terrible price for their altruism and selflessness.
	Of course, the major casualties of the outbreak have been the 8,000 men, women and children who have died so far in countries such as Sierra Leone, Liberia and Guinea. There is perhaps a failure of imagination by us in the West about what a bare statistic such as that means for families on the ground—the individual tragedies that make up the total, with families torn apart and children left without one or both parents. The epidemic may have now reached a peak, I hope, but whether it has or not, one point is certain: we need to examine what measures should be taken to prevent further epidemics on this scale.
	It is also worth remembering that any policy changes that may result from Ebola may also have the effect of helping in the fight against other diseases such as AIDS, TB and malaria, where the death toll is actually even greater. Around the world today there are 1.5 million deaths from AIDS each year, a further 1.5 million from TB and 600,000 from malaria—predominantly of children. The challenge must be to reduce radically this entirely unacceptable total of death.
	What are the lessons that we can draw so far from the latest Ebola outbreak? I suggest that there are at least three. The first is that one of the reasons why the Ebola epidemic has spread so widely, so quickly and with such devastating effect is that in many parts of sub-Saharan Africa health systems are inadequate; the staff are under enormous pressure and their working conditions are often far below what any of us would consider acceptable in this country. Again, there is perhaps a failure to recognise the conditions in which
	medical staff have to struggle to make an impact. A few months ago I went not to west Africa but to Uganda and visited a hospital on the banks of Lake Victoria which had not received a budget increase for 10 years. Inadequate and underfinanced health systems remain the truth in so many African countries.
	Sierra Leone is a prime example. The country lies 11th from bottom of the United Nations Human Development Index. The figures for infant, child and maternal mortality are bad even compared with neighbouring Liberia. Up until the crisis, Sierra Leone, with a population of around 6 million, had something like 136 doctors and 1,000 nurses to care for the population. The Health Secretary said in the other place on Monday that the Government,
	“have committed more than £230 million to fight the disease in Sierra Leone”.—[ Official Report , Commons, 5/1/15; col. 40.]
	That is enormously welcome and makes Britain one of the biggest contributors in the world. However, my concern is not just what we are doing now but what we did before to strengthen the health system and what we will do in the future, because the whole need is for consistent policy applied year after year. My concern is that, once emergencies are over, there is a tendency for countries to fall off the agenda. We treat the casualties but we do not do enough to prevent those casualties taking place.
	An excellent all-party report by the House of Commons International Development Committee, under the chairmanship of Sir Malcolm Bruce, found a strange lack of interest among the NGOs in even giving evidence on the position prior to the Ebola outbreak. The committee would have expected something like 100 pieces of evidence; it received 10. In passing, I pay tribute to Marie Stopes, Plan and Save the Children for being the exceptions to this trend. Unfortunately, the same view seems to have been taken by DfID. In paragraph 33 of its report, the committee found that bilateral programmes directly managed by DfID for Sierra Leone and Liberia were planned to reduce by £14.5 million in 2014-15 compared to the previous year, a reduction of around 19%. The committee commented that it was “appalled” that the budget was being cut in this way. Since then, policy has changed. Emergency money has been put in. A vast effort is being made to help. I welcome that, but my view remains that the priority of policy should be, above all, to provide consistent support for a country such as Sierra Leone, which is one of the poorest in the whole world.
	My second point also concerns consistency. I declare an interest as a non-executive director of the International AIDS Vaccine Initiative, which is a non-profit organisation working to develop a vaccine for AIDS. My point today is a more general one about vaccines. If we can develop them successfully, this can have a dramatic effect, as we have seen in a number of countries in relation to the polio vaccine. But there is one point about vaccine development that is also absolutely certain. They take a long time to develop—sometimes a very long time. For example, the polio vaccine took 47 years to develop and the whooping cough vaccine took 42; with some of the diseases—malaria, for example—the search has been continuing for well over a century. The development time has a number of
	impacts. It means that the pharmaceutical industry is not always able or willing to invest what could be very substantial sums in development. The result is that, in my view, there is a particular responsibility on Governments to finance development here. The United States does a vast amount in this respect. I fear no one would claim that the United Kingdom proportionately does the same.
	The third and final lesson that I believe we should examine is the medical staffing position of some of the poorest countries in Africa to see whether the developed world is taking too many of the doctors and nurses who have been trained in Africa but then come to work and settle in countries of the West and the Middle East, including the United Kingdom, of course. Let me be absolutely clear: the doctors and nurses who have come here have made an invaluable contribution to the health service. There is no doubt about that. But that is not the end of the story. Seen from Africa, the problem is that many of the doctors and nurses who have been trained at some expense have left Africa, which is in vast need of their care, to go abroad. Taking Sierra Leone as an example, around 600 members of National Health Service staff received their primary medical qualification in Sierra Leone. That is small in our terms but absolutely massive in terms of Sierra Leone. Relatively few return.
	I do not claim that it is going to be easy to reverse that trend. It is a question not just of salary but of the medical conditions to which doctors and nurses will return. What we should be aiming at is a situation where there is investment in inward migration but also in outward migration—a two-part thing. It is neither desirable nor possible to have a blanket ban on the immigration and emigration of medical staff. Ideally, it should be a two-way process, as an excellent report by VSO makes clear. But what is clear at the moment is that Africa appears to be a very heavy loser from this process and that we in the West would do well to mount an inquiry to see what can be done to correct that position.
	These are just three questions that the Ebola crisis raises: whether we are doing enough to develop and produce vaccines; whether our policies in the West are taking away a disproportionate number of doctors and nurses from African countries which badly need them; and, above all, how we can further strengthen the health systems of countries such as Sierra Leone so that further human tragedies can be prevented. My hope is that the tragedy of the Ebola outbreak today may point the way to producing more permanent answers for the future.

Baroness Kinnock of Holyhead: My Lords, I thank the noble Lord, Lord Fowler, for initiating this debate and for his extremely thoughtful introduction to the subject, which made many of us think of the complexity of the issue.
	After more than a year, the current outbreak of Ebola continues to destroy lives, livelihoods and communities. It impairs national economies and has damaged already fragile basic services. Ebola is a frequently recurring and fatal disease. Since its discovery
	in 1976, there have been several separate outbreaks with casualty rates as high as 90%. As Kofi Annan has said, it was only when the disease got to Europe and America that the international community really woke up to the crisis. This judgment was echoed by Dr Margaret Chan, the director-general of the World Health Organization. Speaking on the reason for the failure to produce a vaccine or a cure after 40 years, she said:
	“Because Ebola has been, historically, geographically confined to poor African nations. The R&D incentive is virtually non-existent. A profit-driven industry does not invest in products for markets that cannot pay”.
	She made that sombre statement in a world in which 38% of the population do not have access to essential medicines and 50,000 people die each day from largely avoidable causes. Governments and industries should by now have recognised the need for co-ordinated efforts to make registered medicines available at low cost or no cost. Surely Ebola has reminded everyone that, wherever a health crisis occurs, it affects us all. Professor Peter Piot, who first identified Ebola, has said that it would not have been difficult to contain the outbreak if those on the ground had acted quickly but he said that tragically,
	“something that is easy to control got completely out of hand”.
	Investments in healthcare as well as in drugs are essential everywhere. The unimaginable suffering endured in poor countries by poor people urgently needs and deserves a response. Liberia has 51 doctors to serve a country of 4.2 million people. Sierra Leone has 136 doctors for a population of more than 6 million, an average of 0.2 doctors per 10,000 people. There are too many similarly pitiful shortages. Clearly, the reason we do not have a vaccine against Ebola is that the likely victims of the disease are not wealthy enough to pay for the full cost of treatments and medicines.
	The BBC reported this morning that the current epidemic has taken more than 8,000 lives in the three west African countries most affected. The mortality rate is estimated to be 70%. Around 75% of the sufferers in Liberia, for instance, are women who, obviously, are the primary carers and the ones with the responsibility for caring for sick and dying relatives. All three countries lack functioning health systems and access to clean water. They have poor hygiene practices and, generally, an absence of sanitation. According to the NGO WaterAid, such is the enormity of the current challenge that the costs of the emergency response to this crisis will amount to more than the total health and water and sanitation aid committed to Liberia and Sierra Leone over the past five years. That gives us an idea of the nature of the crisis. Lessons must be learnt from the fact that the effects of the response in Nigeria and Senegal have clearly shown that the virus can be contained with a functioning healthcare system and a rapid administrative response.
	There are now signs of some progress, but the epidemic is far from over and experts are urging caution. Infection rates, they advise, could oscillate and reinfection could occur. The WHO assistant director-general has warned against claiming that this very dangerous disease is under control. He said that a few mishandled burials could,
	“start a whole new set of transmission chains”,
	and the incidence of the disease could increase again.
	A report published in last week’s Lancet Global Health by three specialist professors from leading British universities made it clear that IMF conditionalities have required Governments receiving aid to adopt policies that prioritise,
	“short-term economic objectives over investment in health and education”.
	Using IMF archive detail, they came to a view on the effects on the health systems in Sierra Leone, Guinea and Liberia. IMF economic reform programmes,
	“required reductions in government spending, prioritisation of debt service, and bolstering of foreign exchange reserves. Such policies have often been extremely strict, absorbing funds that could be directed to meeting pressing health challenges”,
	with the result that all the countries “failed to meet” the very modest IMF “targets for social spending”, and,
	“to keep government spending low, the IMF often requires caps on the public-sector wage bill—and … funds to … adequately remunerate doctors, nurses and other health professionals … ‘often … without consideration of the impact on priority areas’”.
	Such caps,
	“have been linked to emigration of health personnel”,
	and massive reductions in community health workers.
	The article states that,
	“the IMF has long advocated decentralisation of health-care systems”,
	which,
	“in practice … can make it difficult to mobilise coordinated, central responses to disease outbreaks”,
	and led to a deterioration in the quality of health service delivery. The professors concluded that:
	“All these effects are cumulative, contributing to the lack of preparedness of health systems to cope with infectious disease outbreaks and other emergencies … Although Lagarde’s comment on prioritising public health instead of fiscal discipline is welcome, similar comments have been made by her predecessors. Will the result be different this time?”.
	That is a fundamental question, a matter of life and death. The UK Chancellor and Secretary of State for International Development have governor status in the IMF.

Lord Bourne of Aberystwyth: I remind Members that this is a time-limited debate.

Baroness Kinnock of Holyhead: I must ask the Minister, therefore: what is Her Majesty’s Government’s answer to this problem?

Lord Chidgey: My Lords, I, too, add my congratulations to the noble Lord, Lord Fowler, on bringing this debate to us today and on the eloquent way in which he set it out, for which I am very grateful.
	There are clearly some fundamental lessons to be learnt from the Ebola catastrophe in west Africa, which can be summarised in terms of healthcare practice and provision, public health resources and general infrastructure. The year-long epidemic has now claimed more than 8,000 lives and infected more than 20,000 people. While the number of new cases in Liberia is falling, it continues to rise in Sierra Leone. The data from Guinea continue to be inconclusive,
	underlining the remoteness and inaccessibility of the mountainous forest region through Guéckédou, Macenta and Seredou.
	Apparently the Ebola virus was discovered as long ago as 1976. I can vouch for the fact that in the mid-1980s, while I was working in the Guinea interior along the borders with Sierra Leone and Liberia, villagers would speak to me of their terror of a killer disease that they believed was caught by eating bush meat from monkeys, which may well have been Ebola. At the time, we were doubling the water supply of the capital city, Conakry, but nothing was being done for the remote villages scattered throughout the interior of the country.
	A primary lesson is that by not developing a vaccine to tackle Ebola in the intervening 40-odd years, the pharmaceutical establishment bears witness to the eventual deaths of probably tens of thousands and the infection of many more. The reasoning is unclear, but seems to be associated with concerns over cost recovery from desperately poor communities. However, the cost to the regional economies of decimated and crippled communities does not seem to have been taken into account.
	The decision by the board of Gavi, the Vaccine Alliance to support large-scale vaccination efforts with $300 million procurement funding as soon as a safe and effective vaccine is recommended by the World Health Organisation is very welcome. However, the WHO has been strongly criticised for its slow response to the Ebola outbreak, which to date has affected more than 20,000 people and caused more than 8,000 deaths. There are clearly lessons to be learnt on the effectiveness of the mobilisation, distribution and administration of global health relief.
	The Ebola outbreak has underlined the need for a fresh approach to strengthening health systems in Africa. Strengthening must be community led. Donors need to prioritise and support community ownership of health systems. The top-down approach does not fully appreciate the spiritual, cultural and political undertones to health that exist among many communities and groups.
	The NEPAD organisation of African countries has agreed that each should allocate 15% of GNI to the provision of state-funded universal healthcare, but, so far, there has been little progress. In this context, it seems bizarre that some donors are promoting USA-style healthcare models, based on the principle of private healthcare being purchased by the user, in communities where abject poverty is the norm.
	There is now a thing called “Ebolanomics”, or the role of the pharmaceutical sector, which raises many questions about the interaction between market economies and the pharmaceutical sector. That needs to be analysed, understood and reworked into a modern model that responds to the needs of the global population. Barriers that have prevented earlier development of treatment need to be overcome, with more support being focused on the growth of the African pharmaceutical industry. The current business model needs to be redesigned. What would that model look like? Should there be a legally binding framework
	to guarantee funds to research and to produce and stockpile vaccines for diseases that would otherwise be neglected?
	An unforeseen effect of the Ebola epidemic is its impact on programmes to tackle other pandemics, in particular malaria. The Ebola virus is distracting attention from other diseases that still ravage west Africa. Malaria patients in Sierra Leone, Liberia and Guinea—the countries worst effected by Ebola—are now so terrified of the impact of the virus that they will not attend their local hospitals where their malaria could be easily treated with a package of available drugs. Fatoumata Nafo-Traoré, head of the UN’s Roll Back Malaria Partnership, says that without the necessary treatment, malaria patients are going to die.
	The economic impact of Ebola on the sub-Saharan region as a whole will be significant, according to Roger Nord, deputy director for Africa at the IMF, who spoke at an Africa All-Party Group meeting recently. He reported that if it takes another nine months to get the outbreak under control, it is expected to reduce growth in Guinea by 1.5% and by around 3.5% in Liberia and Sierra Leone. Neighbouring countries such as Senegal and the Gambia are also starting to see tourism activities decline.
	Margaret Chan of the WHO, while recognising the delayed international response and the need for increased international funds, has said that more important than anything else is the need for community funding and support. In this regard, community-level media and radio have an essential role to play, and I pay tribute to the work of the BBC World Service and BBC Media Action, which work with local FM stations that are trusted by their communities. In particular, I pay tribute to BBC reporters in the field who have overcome formidable physical obstacles to reach the most isolated communities in the grip of the Ebola virus.
	Much of the work to defeat Ebola is being done by local people. Nigeria and Uganda have sent hundreds of health workers and South Africa has contributed significant funds. The media have a responsibility also to report what African people and Governments are doing to fight Ebola.

Lord Patel: My Lords, I, too, thank the noble Lord, Lord Fowler, for initiating this debate. I thank him also for his brilliant speech and for his great concern for those who volunteer to do this work. I associate myself with the comments that he made about Pauline Cafferkey and I wish her a speedy and complete recovery.
	I want to speak on four issues as far as the lessons learnt are concerned. Could the crisis have been spotted earlier? Was the UK’s response timely and appropriate both in scale and support? What needs to happen to cope with future pandemics? Did the UK have appropriate safeguards for NHS and other volunteers who went to Sierra Leone, including on their return?
	Peter Piot, in his book No Time to Lose, described the dramatic effects of Ebola infection since its outbreak in 1976 and warned us to be prepared. Previous outbreaks were controlled by prompt notification, deployment
	of specialist teams, quarantining of exposed individuals and isolation of patients, but the lessons were not learnt. The current outbreak started in Guinea at the end of 2013. Despite hundreds of deaths, neighbouring countries did not take any notice. Surveillance systems were not effective and warnings from organisations such as Médecins Sans Frontières were ignored. Official agencies were either complacent or did not have the resources or personnel in place to monitor the outbreak. Hundreds died. Worse, in countries where health workers were in poor supply, several hundred health workers died.
	Did the WHO botch its response to the developing crisis in Sierra Leone and Liberia? The answer is most likely yes, but the question is why. Africa office representatives were not filing Ebola reports to the head office. There are lessons here as to how the WHO, the only global health agency, should operate in the future and how its performance could be improved. There is no doubt that its effectiveness was weakened by decades of policy failures and budget cuts by wealthy nations trying to fund their deficits. Wealthy nations need to restore their funding of the WHO. The Ebola crisis has confirmed a new reality: that we live in a shrinking world. To cope with future pandemics—which are sure to come and might be worse than the current pandemic—strong international organisations working with national organisations is absolutely necessary.
	My second point relates to the UK response. Here I can do nothing but congratulate the UK Government on the speed with which they responded, with both personnel and finances—the second-highest donor nation after to the United States—and commend the continuing effort that DfID and WHO are making to bring this crisis to an end. We need to learn lessons as to whether we could have done better—it is always possible to have done better—but, hitherto, I have nothing but praise for our Government.
	This leads to my third, and important, point—already mentioned by the noble Lord, Lord Fowler, and other noble Lords: what should we do about future pandemics? Why were countries such as Guinea, Sierra Leone and Liberia not able to cope with the crisis, when countries such as Nigeria curtailed it very quickly? The answer is very poor health systems, as has been mentioned: lack of facilities or equipment, deficit of a health workforce, lack of appropriate public health measures, and lack of surveillance and controls. Both Larry Summers, the previous Treasury Secretary of the US, and Bill Gates, when he spoke in the Robing Room, asked for help in developing health systems in those countries.
	Larry Summers’s report, Global Health 2035, published in the Lancet, identifies that we will need some $30 billion a year for the next decade. Building health systems requires time and money, and the richer nations of the world need to come up to the plate to develop that. Otherwise, we will continue to have such crises, which will begin to affect us even more than they do now. The UK can take a lead in building health systems. We are the right country to do so because we have demonstrated that we can have effective influence.
	My fourth point relates to whether the UK’s support for our NHS volunteers has been appropriate. It is important that we make sure that people who volunteer
	to go to affected countries are in a safe environment, are able to work safely and can return home safely afterwards. Comments that we have seen in some of the media, particularly social media, demonising those who return from such work, are unacceptable. Sarah Wollaston, MP for Totnes and chair of the Health Select Committee wrote a very good article about this in the
	Telegraph
	. I was disappointed to learn—if accurate—that some BBC staff feel that they can no longer interview in person people who come back from west Africa, and therefore that a telephone interview would be more appropriate. Brave BBC workers have reported from there, but such comments from the media—if correct—are also inappropriate.

Lord Giddens: My Lords, I also thank the noble Lord, Lord Fowler, for securing this debate and introducing it in such compelling fashion. I join noble Lords in paying tribute to Pauline Cafferkey as she struggles for life in a hospital not far from where we are today. The latest report on healthcare workers who have died from Ebola puts the number at 500 rather than 400, which shows the awful toll it is taking in so many different areas.
	I will concentrate on the economic consequences of the epidemic, to which the noble Lord, Lord Fowler, alluded. There is another tragedy unfolding alongside those of a medical and humanitarian kind. Prior to the Ebola episode, all three main states involved experienced strong economic growth following years of war and inept or tyrannical rule. Growth rates have already halved in Sierra Leone and Liberia and could even turn negative in Guinea. Tourism has come to a halt, as the noble Lord mentioned. Restrictions on mobility severely hamper trade. Agricultural production—a key area in all three countries—is way down. Rising food prices have helped create steep inflation—a very unpleasant economic scenario—which was running at more than 13% in Liberia in 2014. That situation could quite easily get completely out of hand. Meanwhile, investors are running scared and there is a serious risk of capital flight from these countries. Economically, this has the makings of a truly tragic situation.
	The emancipation of women is a key aspect of economic development in emerging economies. Many women in the labour market have turned instead to the care of sick family members or others in the community. In Sierra Leone, for example, women were heavily represented in cash crop production, local trade and microenterprises. Many had to quit and most are highly unlikely to re-enter the labour force at any time soon.
	As a result of this, I have three basic questions for the Minister to comment on. Like the noble Lord, Lord Fowler, and other noble Lords, my great fear is that if and when Ebola is effectively contained in west Africa, the international community will lose interest in the countries affected. Can we avoid them sinking back into despair and perhaps fragmentation? The possibility is very real that these countries could be worse than back to the point zero of some years ago when they were racked by war. These are, as every noble Lord knows, among the poorest societies on the
	face of the Earth. We must ensure that the international community does not lose interest if it appears that the epidemic can be contained—although some medical specialists now say that it could become endemic, which is an additional worry.
	Secondly, how will the Government assess the success or otherwise of the World Bank in the budget support it pledged to facilitate trade, investment and employment in the three countries involved? The World Bank promised substantial sums of money. Does the Minister have any information about whether any of that money has been forthcoming? As we know, promises are easy to make. The sums involved were very large and it would be good to be updated on that if the Minister has that information.
	Thirdly, it is clear that regional aid and investment will be crucial, coming from surrounding African states. How much progress has been made with the fund for renewal set up by the Economic Community of West African States? Any western intervention concentrated on the three principal countries must also seek to involve other African countries, and perhaps fund them in addition so that they can help the three countries most affected.

Baroness Hayman: My Lords, like other speakers I congratulate the noble Lord, Lord Fowler, on introducing this debate and his consistent commitment to health in the developing world. I am delighted to be able to take part in the debate but fear my contribution would probably be more useful in five weeks’ time, when I will have returned—I hope—from a visit to Sierra Leone to see for myself the work of some of the agencies with which I am associated. I declare my interests in those, recorded in the register.
	Many lessons of the Ebola outbreak are already emerging. The speed of response is one that others referred to. The need for the international community to have a plan that is both flexible—because not every emergency is the same—and already funded is tremendously important. We all have a responsibility to look at how the international community could prepare for further outbreaks. As others said, not only will they occur but we cannot consider them to be someone else’s problem. Ebola is not an airborne disease, for which we all throughout the world must be extremely grateful, but other diseases are airborne. The interconnectedness of health in our global world is a lesson we must learn.
	Another lesson that no one will quarrel with is that, however much international aid and however many volunteers—I, too, pay tribute to them—we parachute into a situation such as the one we have seen in west Africa, there can never be enough to replicate a basic health system that reaches into every village and community and is the absolute foundation not only of public health in normal times but of dealing with disease outbreaks. What we as a world do post-2015 in terms of the objectives for health and providing support for health systems will be tremendously important.
	That will be shown in Sierra Leone because, as others pointed out, once Ebola is, we hope, no longer rampant—the noble Lord, Lord Giddens, rightly pointed
	out there is a possibility of it becoming endemic in the country—there will still be a tremendous specific health need left behind by the effects of the crisis. There will be the patients with malaria. We have a seen a terrible spike in malaria deaths. There will be the women who died in childbirth because they were not able to get to attended facilities. There will be the health of the orphans left behind. There will be the vaccination programmes that have been interrupted. There will be a tremendous health need. As the noble Lord, Lord Giddens, said, it will be a test of us all that we do not walk away from that at the end of this process.
	The other lesson that we can learn is that we can rightly be proud of the response of professionals in this country who have volunteered, of the British public, who have given more than £30 million to the Disasters Emergency Committee, of which I am a trustee, and the work of the agencies funded by that money, which goes far beyond medical treatment to provision of food and latrines for people who are in isolation, the care of Ebola orphans and safe burials. That is a tremendously important contribution.
	We should also pay tribute to those in the affected countries in Africa. I will also be considering the work of Restless Development, the charity that my husband chairs, which has about 2,000 community volunteers in the field working on social mobilisation. The trust and behaviour change of communities that is needed is on a tremendous scale and does not come from lecturing by people from outside; it comes from the mobilisation of community leaders, religious leaders and individuals who are connected to their communities, who are trusted and who give the right messages and support people to change behaviours to protect themselves.
	An understanding of the need to marry the command and control and international response with the grass-roots, culturally sensitive response of those on the ground, is something that we hope we can learn from this outbreak. I cannot finish without endorsing what the noble Lord, Lord Fowler, said about vaccines, to which the noble Baroness, Lady Kinnock, also referred. We have a market failure in vaccines and medicines for the poor. We cannot simply shrug our shoulders and say that the pharmaceutical industry as currently constructed can and will never produce the goods. We need to ensure, through government, philanthropy and voluntary organisations, that those goods are produced for the poor.

Lord Collins of Highbury: My Lords, I, too, thank the noble Lord, Lord Fowler, for ensuring that this vital issue remains high on the political agenda. Last November, my noble friend Lady Kinnock initiated a similar debate, and many of the concerns raised then remain relevant today. The Government’s response on the ground has been positive, so far providing more than £200 million for treatment, facilities, expediting NHS staff who heroically volunteer and helping to finance trials and develop new treatments and vaccines for Ebola.
	The UK medical workers who have volunteered in their hundreds to join the fight against Ebola in Sierra Leone are playing a critical role in the front-line
	response. The tragic case of nurse Pauline Cafferkey highlights their exceptional bravery and compassion. My thoughts—and, I know, those of everyone here and all noble Lords—are very much with Pauline and her family during this very difficult time.
	As we heard from the Statement in the other place on Monday, Save the Children is conducting an urgent review, which I understand will involve representatives from Public Health England. Clearly, the sooner we know the results, the better. Can the Minister update the House on the review? When are the results likely to be published? As the next group of NHS volunteers leave for west Africa in the coming weeks, they will want to know whether procedures and guidance will be changed in the light of that case. Will the noble Baroness also liaise with the Department of Health to ensure that the employment and careers of volunteers who show their compassion are not adversely affected by any further quarantine restrictions that may be introduced following the review?
	The role of British volunteers has been significant in the campaign against Ebola. What plans do the UK Government have to establish a standing roster of medical workers for possible deployment in future health emergencies? As we have heard in this debate, this crisis underscores the importance of investing in a strong system of research and development for global health. In Justine Greening’s own words, new technologies are,
	“vital if we are to improve the health of the poorest people through better treatment and prevention”.
	The UK Government have shown leadership in supporting solutions, including product development partnerships. PDPs have been instrumental in bringing through 37 new therapeutic products for poverty-related diseases registered over the past decade. Will the Minister commit to prioritising within DfID, and promoting among other key donors, the need properly to fund and support R&D for global health?
	The three countries facing the largest burden of Ebola are among the poorest countries in the world and, as we have heard, have some of the most fragile health systems. They have had insufficient investment in infrastructure, the healthcare workforce, health information systems and medical supplies and equipment over decades. What is the Minister’s assessment of the state of preparedness for Ebola in neighbouring countries? What plans do the Government have to provide specific support to the high-risk countries on the WHO watch list to reduce the risk of further outbreaks? What is the Minister’s assessment of the factors contributing to the decline of cases in Liberia? What lessons from Liberia are being applied to the UK response to Ebola in Sierra Leone?
	As we have heard in this debate, the main issue has been health systems not being resourced or strong enough to deal with the issue. That is a key factor. Universal health coverage, whereby there is access for all without people having to suffer financial hardship when accessing it, is a key way that we can make countries more resilient to health concerns such as Ebola before they become widespread emergencies. Universal health coverage is a clear and quantifiable goal, and 2015 is the year when international development
	will be high on the international agenda. On 19 January, negotiations start in New York on the replacement of the millennium development goals. I know that I have asked this before, but I ask the noble Baroness to support universal health coverage in the language of the health goal in the successor to the MDGs, the SDGs. I ask her to back that strongly because, as we have heard in this debate, universal health coverage is the key to avoiding such catastrophes in the future.

Baroness Northover: My Lords, I start by thanking my noble friend Lord Fowler for securing this important debate and all noble Lords who have contributed for their considered responses. As my noble friend Lord Fowler and others have made clear, this epidemic has terrible individual consequences, as well as wider social and economic consequences.
	I join noble Lords in my extremely deep concern for Pauline Cafferkey. The Royal Free has just issued a statement, and I understand that her condition remains critical and is unchanged. The bravery and compassion shown by Pauline and her colleagues have helped to save thousands of lives in Africa. Like my noble friend Lord Fowler, I pay tribute to all those who have volunteered to help in that dreadful crisis. I here commend the son of the noble Lord, Lord Patel, Dr Neil Patel, as he undertakes his own challenging tasks in Sierra Leone, leaving shortly. It is vital that we never compromise the safety of such extremely brave volunteers and I can give the Government’s unequivocal commitment on that. Clearly, Save the Children and Public Health England keep this under constant review. They are reviewing the situation at the moment and we will update noble Lords as soon as possible.
	I note what the noble Lord, Lord Collins, said on that and what he said about standing rosters. We have taken forward quite considerable amounts of development to ensure that those who wish to volunteer are properly trained before such a crisis and are able to be deployed in humanitarian disasters. There is new training offered by the Royal College of Surgeons to ensure that those who volunteer are safe and effective in dealing with the need in question, so I hope that the noble Lord will be encouraged to hear that. Guidelines on this particular crisis are kept under review all the time.
	Noble Lords will appreciate that DfID is still focused on containing and eliminating the Ebola virus in Sierra Leone, where the UK has the leading international response. I thank the noble Lord, Lord Patel, for his tribute and I will pass it on to my outstanding colleagues in DfID. So far, we have committed more than £230 million to combat Ebola in Sierra Leone, and have already delivered more than 1,200 treatment and isolation beds and three new Ebola testing laboratories. We are also working closely with the Government of Sierra Leone to train and equip burial teams to ensure safe burial practices.
	The noble Lord, Lord Collins, mentioned differences in Liberia. I am sure he will know that there are all sorts of cultural differences between the two countries—different social norms and so on—which underpin what has happened in them in this epidemic. I am quite happy to go into further detail outside as to why there have been differences here.
	As the noble Baronesses, Lady Kinnock and Lady Hayman, indicated, there are tentative signs that we may have reached the peak of the disease in Sierra Leone. But as both were saying, we should not be complacent; the response is far from over. Like my noble friend Lord Chidgey, I pay tribute to the response that has come from African countries.
	The economic impact of this should not be underestimated. Various noble Lords, including the noble Lord, Lord Giddens, made reference to that but I think we are all aware of it. The noble Lord also flagged the financial commitments of the World Bank. We are acutely aware that promises do not necessarily get delivered and we are working very hard to ensure that, where promises have been made, they are duly delivered.
	We agree that a long-term interest in affected countries is essential to ensure recovery. The EU is convening a meeting in early March to look at resources for this and the WHO has a special session in late January to agree reforms, so a number of things are under way.
	While our principal focus must continue to be on the ongoing response, it is essential, as my noble friend Lord Fowler pointed out, that we learn lessons from these actions both here in the United Kingdom and internationally. This Ebola outbreak has been unprecedented. More than 8,000 people have died and it is crucial that we make changes to ensure that this never happens again—and that lessons are carried over for other potential epidemics, as was pointed out by noble Lords, in particular my noble friends Lord Fowler and Lord Chidgey.
	It is evident that international reform is required. The World Health Organization and the wider international system did not respond quickly enough to this threat before it got out of control. While progress has been made in efforts to strengthen global health security following SARS and avian flu outbreaks, the Ebola outbreak demonstrates that there is still much to do in responding efficiently to public health emergencies. As I have mentioned, the WHO executive board is convening a special session later this month to examine some of these issues, and I am sure that the points made by noble Lords, including the noble Lord, Lord Patel, must be considered. In particular, we need to look at surveillance, stronger early warning and response mechanisms, and how the global community identifies and responds to potential crises in the future. Like the noble Baroness, Lady Kinnock, I noted that Nigeria managed to check cases in the initial stages and it should be commended for that. Lessons needs to be learnt from how that was achieved, even though, again, we cannot be complacent.
	The international community needs to be ready to respond rapidly and deploy public health experts immediately. The noble Baroness, Lady Hayman, had a number of important perceptions here as to changes that might be needed and the way in which the international system needs to link to what happens within a particular country and be sensitive to the arrangements and the views, beliefs and practices within those countries. This was a point which my noble friend Lord Chidgey also made.
	In linking to national systems, a number of noble Lords emphasised the importance of strengthening health systems. We have been investing heavily in strengthening health systems in Sierra Leone through our bilateral aid programme but, barely 10 years after the end of a devastating civil war, health systems are still fragile and unable to cope with a crisis of this scale. My noble friend Lord Fowler made it crystal clear that the weakness of health systems is fundamental in this case. International support from DfID, but also from the World Bank, IMF and UN, will be critical in supporting Sierra Leone and the wider region to recover from this devastating crisis. Supporting the health sector ravaged by Ebola will be a priority, as well as supporting vulnerable groups such as orphans, children, women and girls.
	I heard what my noble friend Lord Fowler said about consistency in support. That seemed to me to be an argument for the 0.7% Bill, which will come before this House on 23 January. I hope that noble Lords will support it. The aid budget has often been subject to easy battering in the past. Consistency and predictability are vital, which is why it is important to legislate for that level of aid. I welcome the support of the party opposite on this. Investment in human development is vital to the elimination of poverty and the growth of developing countries. I can assure noble Lords that we fully recognise that. In DfID, 20% of our budget in Sierra Leone has been spent on health programmes, and that will continue to be the case when this crisis is over as well. We agree that weak health systems in the affected countries have contributed to the rapid spread of Ebola.
	We also agree that there has been a significant drop in the utilisation of health services, a point made by my noble friend Lord Chidgey and others, including the noble Baroness, Lady Hayman. We are therefore working with experts to determine strategies to decrease malaria deaths, including using new drugs and making sure that there are adequate stocks in Sierra Leone to try to address this. We recognise that it is vital to prepare the health sector for future shocks and have started to consider this challenge. National institutions are crucial but we also recognise that it will take time to build up health systems capable of dealing with major epidemics. That is why we focus on poorer developing countries; that is where the need is greatest.
	To improve response to infectious disease outbreaks we need to ensure that, as far as possible, we have proactively identified potential diseases and developed technologies such as vaccines and treatments to address them. A number of noble Lords made this point. We need to be able to deliver rapidly clinical trials of promising candidates, resolve intellectual property disputes over them, scale up production, put in place adequate delivery capacity and manage the increased liability risks, while securing financing for all this.
	I would dispute what my noble friend Lord Fowler said about reducing our aid spend in Sierra Leone. In 2010-11, we spent £51 million; in 2013-14, it was £69 million.
	Our support for vaccines has been a major move by DfID under this Government. My right honourable friend Stephen O’Brien was quite remarkable in the
	way that he brought forward the proposals on support for what were called neglected tropical diseases, and I think that people will pay tribute to him and DfID for the work that was done. I think that we have a strong record in this regard, and that is something that we will continue to focus on and to regard as very important.
	Our focus remains on ridding Sierra Leone and the surrounding region of Ebola. It is critical that we learn the lessons from this crisis to ensure that it never happens again. We realise how a crisis like this affects us all and how it has devastating consequences, both individually and more widely on societies and economies. We understand that, and we all need to see what lessons need to be learnt and then—most importantly, as the noble Lord, Lord Giddens, indicated—acted upon.

National Health Service
	 — 
	Motion to Take Note

Moved by Lord Turnberg
	That this House takes note of the future of the National Health Service.

Lord Turnberg: My Lords, it is a privilege to be able to open this debate on the future of the NHS. It comes at a time when we are gearing up for the election and when it seems entirely possible that the NHS will be of some interest to the electorate. I will try to set the scene with a broad brush and leave it to other noble Lords to focus on various specific aspects.
	We are going through a time when the media are full of one NHS disaster after another; with reports of cancelled operations, GPs and A&E departments being overwhelmed and waiting lists rising. We have not been short of media analysis in the past few days. That this is not simply the usual media hype is pretty obvious. We have had a number of careful reports from the Nuffield Trust and the King’s Fund, for example, that make sobering reading, with titles such as Into the Red? The State of the NHS Finances and Is General Practice in Crisis? suggesting that all is not well and that we cannot continue as we are.
	The Government have woken up rather belatedly, with a sudden rash of activities. We have had NHS England’s Five Year Forward View, full of interesting aspirations; the Dalton review, with some ideas about how to go about achieving some of them; a number of crisis funding rescue efforts; and the Prime Minister reportedly sending in his pre-election “hit squad” to try to sort things out. However, it is pretty clear that quick fixes are not the answer and that the nature of the difficulties we face requires much longer-term solutions. It is good to hear that my own party is making some realistic proposals that might make a difference.
	The causes of the problems are pretty widely understood. A service designed largely around acute hospital care has ignored for too long the needs of people with multiple long-term illnesses, especially those of the growing band of elderly patients whose needs are much better met in the community than in hospitals. This demand is certainly rising. The number
	of over 80 year-olds is set to double over the next few years and, for example, the number of people on more than three different pills for their multiple illnesses is growing by the day. I dare say that there will hardly be a Member of your Lordships’ House who is not on at least two pills keeping them in the fine trim that we see today, and I fear that I am no exception.
	However, it is not only the growing proportion of the elderly and the worrying rise in the number of people with dementia that is causing difficulties; it is also the pressing demand placed on acute services. We can do so much more for patients than we ever could, and the population increasingly expect that they will be given the most effective treatments available. Many of those treatments are now very expensive. Complex scanners and investigations, coupled with the development of designer drugs produced specifically in response to an understanding of the genetic make-up of smaller and smaller subsets of patients, pose severe problems for a service working within rigid financial constraints.
	It is in that financial squeeze where the nub of the problem lies. The fact is that the rate of inflation in health service costs is running way ahead of general inflation rates and certainly ahead of the growth in GDP. So every year the gap between demand and the funds available is widening, and this is what is responsible for the idea so often trotted out that the NHS is a “black hole” into which money just disappears. I do not believe that for a moment, and I will explain why shortly.
	You might think that a Government would try to keep pace, if not with inflation then at least with the rise in GDP, small though that might be. In fact, the slice of the national cake devoted to health has gone down from about 8.5% when Labour left office in 2010 to 7% now—that is a fall of 17% in our share of the nation’s wealth. Even worse, predictions by the King’s Fund point to a further fall to 6% of GDP by 2021, on the current Government’s projections. That, I suppose, is all part of their plan to reduce overall public expenditure to pre-1940s levels, despite their protestations about a desire to protect the NHS.
	It might be asked why these problems seem to have become much more acute in the past few years. After all, we have not all suddenly become older and sicker. The fact is that when Labour left office five years ago we had managed to get rid of waiting lists, patients were seen on the same day by their GP and patient satisfaction levels were high. It is no coincidence that we had appointed some 130,000 more front-line staff to cope with demand. So what has happened that left us with our current difficulties? Certainly, the distractions of the Lansley reforms did not help, with all the redundancies and re-employment of senior managers and the loss of continuity in leadership that followed. As Maynard Keynes said:
	“It is not sufficient that the state of affairs which we seek to promote should be better than the state of affairs which preceded it; it must be sufficiently better to make up for the evils of the transition”.
	I fear that we are still suffering from the evils of transition.
	Then we have had the Nicholson challenge and the so-called efficiency savings of no less than £20 billion over the past five years. Of course anyone working in
	the service knows that it is always possible to improve efficiency, but now it is clear that the pips are being made to squeak too loudly as we run out of such short-term measures as wage freezes and the like. The inevitable result is that we are failing to keep up. GPs are overwhelmed, waiting times in A&E departments are rising, waiting lists are growing, social service departments are failing to cope and many such departments are now able to deal only with those in most serious need.
	So what is to be done? I shall focus on four specific areas: disease prevention by public health measures; bringing hospital and community services much closer together; focusing on some specific aspects of care where we are clearly failing, namely A&E services, general practice and mental illness; and stimulating much more research and innovation where the potential dividends in health and well-being, as well as economically, are considerable. Of course none of these sounds entirely novel, but the fact is that we have failed miserably to achieve them so far. I want to examine why that is the case and what we should do now to ensure that we do not fail again.
	First, with regard to prevention with the aim of reducing demand, no one can argue with the need to try to prevent the many illnesses caused by smoking, drinking too much alcohol and eating too much food. That is why I believe that the Government must get on with the plain packaging legislation, for example. We also know that the most effective measure to reduce alcohol consumption is to increase the duty on alcohol. It is pretty clear that whenever the price of alcohol goes above the rise in the general cost of living, the incidence of death from liver disease goes down—and, let’s face it, the increased revenue generated could make a useful contribution to the Exchequer and the NHS. I will leave it to other noble Lords to go into why the Government are reluctant to use this most effective measure, but the problem here is not that these are not vitally important things to be doing—they clearly are—it is the expectation that we will see financial savings from doing them in any reasonable timespan. Any impact on costs will inevitably take time.
	Secondly, I turn to the need to see much greater co-operation and collaboration—what we used to call “integration”—between community-based and hospital services. The report from Sir David Dalton provides some very helpful ideas about how this might be achieved. He, of course, has managed to show how it is possible to integrate services extremely successfully in Salford and his report describes a number of other potential models for collaboration that fit in with different local circumstances. Clearly, the removal of the barriers between hospital and community is highly desirable and the idea of pooling health and social care budgets could be a very supportive measure. However, we have to be sure that current competition laws do not get in the way, and even more importantly, we have to be clear that the funds are available to facilitate this transition. It would be naive to believe that it could be done within existing budgets, even though in the longer term that sort of joined-up service will be more efficient, and of course it will suit patients’ needs much better. But in the short to medium term, it will need transitional funding.
	The idea behind the Government’s better care fund was to try to bolster community services at the expense of the NHS, which itself is pretty cash-strapped. Robbing Peter to pay Paul is never going to be popular with Peter, and we now have the lowest number of beds per head of population than anywhere in the western world. If we are to see this vitally important change in the way services are delivered, we have to accept that fresh money will have to be found from somewhere.
	Thirdly, I turn to three of the biggest challenges facing the NHS at the moment: problems in general practice, gaps in mental health services, and the troubles in A&E departments. The problems in general practice have been well rehearsed. I had a letter from a young general practitioner the other day in which she encapsulated the difficulties she faced. She said she was increasingly exhausted as her workload just seemed to grow and grow. She pointed to the shortages of practice nurses and care workers, the difficulty in recruiting to those posts, the fact that many of her colleagues were retiring early and that general practice was becoming a very unpopular option for young medical graduates. It seems likely that that is the reason why it has proved difficult for the Government to encourage medical schools to get 50% of their graduates into general practice. It is striking, too, that she said that she had to spend up to 50% of her time in administration. What a waste of her valuable time, which could be much better spent in dealing with her patients.
	So there is much to do there. We need to recruit and train more support staff, especially practice and district nurses, who are in such short supply; we should bring together bigger groupings of general practices into multipractices or the like so that there are economies of scale; we need to recruit and train more GPs by making the job much more attractive; and we definitely need to reduce the horrendous bureaucratic burden under which they labour. I am afraid that once again your Lordships will have noticed that none of that can be done without some additional funding.
	On accident and emergency departments, which have been in the news so much of late, there is this somewhat optimistic view that once we have stopped people smoking, drinking and eating too much and once primary and community care is up to scratch, the pressures on A&E departments will disappear. But that, of course, is some considerable way off and it denies the evidence from everywhere else in the civilised world that there is a universal rise in A&E visits. So, once again, moving the deckchairs here will not solve the problem and it seems inevitable that more funds will be needed to recruit and fill posts, both medical and paramedical, in these desperate departments. We are clearly wasting far too much money on expensive locums when that money should be directed to permanent posts.
	Mental illness, despite much rhetoric about parity of esteem between physical and mental illness, remains a Cinderella service. I suspect that other noble Lords will expand on this, but there can be little doubt that more resources are needed there, too.
	Finally, I will say a few words about research and innovation in the NHS. The UK has been pretty successful in supporting medical research through both public funds and the research charities—and here I should express my interest as scientific adviser to the Association of Medical Research Charities. Some good things are happening here: for example, with the National Institute for Health Research, under the direction of Dame Sally Davies with the strong support of the noble Earl; the Health Research Authority is streamlining ethical approval; and the MHRA is providing quicker routes for licensing new medicines. However, there are many problems, too, because while we may be good at research, we are too often sluggish in taking up innovations. There are concerns that future funding for NIHR and its invaluable academic health science networks and centres remains uncertain, and there are also worries about the willingness of CCGs to support the Charity Research Support Fund. We are also failing to encourage and support those entering a clinical research career while their conditions of service are being neglected.
	A tortuous funding approval process also gets in the way. It may come as some surprise to learn that to get the approval of NHS England for a new medicine to treat a rare disease there are no fewer than eight committees through which it has to go. It has been said that if you want to avoid making a decision, set up a committee. If you want never to make a decision, set up eight committees. That is a case where NHS England needs to look at its own efficiency, and if it is just an example of its committee structures, it has some way to go.
	In the pressure for ever more efficiencies, we must avoid being so short-sighted as to leave research and innovation to wither away. The dividends we will lose are just too great. I believe we know what should be done—there is a growing consensus on that. However, it is increasingly clear that without an input of more resources we will not be able to rescue the NHS from this downward spiral. Even Simon Stevens, the chief executive of NHS England, has said as much. The next Government will have to face up to this issue and square with the public about how they intend to protect an NHS and a social service system that is so precious to them and to focus on the sources of the increased funds that are needed. I look forward to the speeches of other noble Lords and to the Minister’s response.

Baroness Jolly: I remind the House that time is very tight, so I ask noble Lords to keep their remarks to six minutes. When the clock shows six, your time is up.

Lord Horam: My Lords, I think we are all very grateful to the noble Lord, Lord Turnberg, for initiating this debate. Obviously, it could not be more timely. He may recall that he and I first met when he was president of the Royal College of Physicians and I was a Minister at the Department of Health. Even then, we had the same post-Christmas problems—we may also be taking the same pills, for all I know, but I will not speculate on that.
	I will put forward two particularly positive points as we review the situation, which is obviously worrying, and the longer term situation, which the noble Lord wants us to address. The first is that the NHS remains a good and a tried and trusted model for the delivery of healthcare. If you look around the world, it is very difficult to find one that is better as regards value for money and quality—although we know that there are gaps. It is also, as my noble friend Lord Howe pointed out in his Statement yesterday on the winter problems, remarkably flexible when it needs to be. We see that a number of hospital trusts are coping with these sudden increases in demand in a very innovative and sensible way.
	The second positive point I will make is that there is wide consensus—although one would not think so in the political debate that is going on—over the way the NHS should evolve. I will concentrate in my short remarks on the Five Year Forward View, which was produced by Simon Stevens, the chief executive of the National Health Service England, in October last year. That has received general support from all sides of politics, and it was both realistic and sensible. However, the conclusions it reached have been underplayed. The central conclusions Simon Stevens points out in his report’s final two paragraphs are that even if funds remain broadly flat in real-terms increases—and in fact, despite what the noble Lord, Lord Turnberg, said, spending on the National Health Service and on health in this country as a whole has more than doubled in real terms since I was a Minister back in 1997—and if the service continues its annual increases in efficiency of 0.8% a year, which is not a huge annual increase, the £30 billion gap which he envisages by 2020 would reduce to £21 billion. If the increase in efficiency was doubled to 1.5% every year—again, not a huge increase—it would reduce that £30 billion gap to £16 billion. If efficiency could be increased to 2% to 3%, which is quite normal in other industries and services, the funding gap would be almost wholly eliminated and we would be able to reach the nirvana of a continuingly progressive and successful health service.
	In that context, I make one suggestion to my noble friend Lord Howe. We know that many hospital beds are occupied by people who do not need to be there, who do not need acute care any longer, and who could be in a recovery situation or intermediate care elsewhere. It is the fact that many housing associations and mental health trusts have been lobbying hospital trusts up and down the country, asking to provide intermediate and recovery units for them, so they can transfer patients from acute services into those intermediate or recovery services. I noticed on the BBC last night that a trawl had been done of where the problems were; a spokesman for Addenbrooke’s Hospital in Cambridge said that 20% of its beds were occupied at this moment by people who could be cared for in a recovery unit or in another form of intermediate care. But the housing associations and mental health trusts are finding that, although very often the chairman and CEOs of hospital trusts are glad to have this support, it is simply impossible to get decisions. The noble Lord, Lord Turnberg, pointed out that among other things it is very difficult and
	slow to get decisions through the bureaucracy of even the trusts themselves, let alone the overall NHS, and this is causing a real problem.
	I hope that my noble friend Lord Howe will look at this issue, where there could be an immediate improvement, within a matter of months, in the number of facilities being taken up by people who do not need to be in hospitals. It would save the capital costs, because housing associations would pay for them out of their own capital funds. It would also save current costs, because an NHS bed costs £2,000 a week to maintain. The housing associations tell me that they could do it for less than £1,000 a week, halving the current costs as well as providing capital money for the NHS. So there is an example of where efficiency savings could be made in a very short space of time. We are talking about months or even a year or two.
	Simon Stevens’s conclusion, following the final two paragraphs of his report, was that,
	“nothing in the analysis above suggests continuing with a comprehensive tax-funded NHS is intrinsically undoable”.
	I believe that to be correct and right, but we will achieve that only if the trusts up and down the country stop being just administered and manage the resources, using the funds available to them properly.

Baroness Jay of Paddington: My Lords, I congratulate my noble friend on his timely debate, which has become even more relevant in the face of the tsunami of so-called special incidents which are apparently swamping the NHS at the moment. On the face of it, the A&E tsunami is rather unlike the other winter crises that we have experienced. After all, the weather is not particularly severe and we are not experiencing a threat from a new infectious illness, such as SARS, or even a normal seasonal flu epidemic. Indeed, as was rightly asserted in this House yesterday, much of the primary cause of the present situation is government policy—and, specifically, the reduction in social care and the fragmentation of health services to which the noble Lord, Lord Horam, referred.
	The only possible political silver lining that I can see is that the Secretary of State Mr Hunt seems to recognise that he is accountable and responsible for what is happening. I was surprised and somewhat relieved to hear him say yesterday in Commons Hansard:
	“I take responsibility for everything that happens in the NHS”.—[Official Report, Commons, 7/1/15; col. 277.]
	That is in sharp contrast to his attitude last autumn when the Secretary of State received the Five Year Forward View as though it was a rather interesting contribution from an independent think tank. In exasperation in response to that, the shadow Secretary of State, my right honourable friend Andy Burnham, commented:
	“I do not know who runs the NHS these days, but I do know that it is certainly not him”.—[Official Report, Commons, 23/10/14; col. 1045.]
	He also said that this was a clear illustration,
	“of the serious loss of public accountability”,
	following the 2012 reorganisation Act.
	Those of your Lordships who took part in the long drawn-out proceedings on that Act in this House will remember the battles that we had to retain the central responsibilities of the Secretary of State in the legislation, responsibilities that had after all been there since 1948. We eventually succeeded so that the Act now reads:
	“The Secretary of State retains ministerial responsibility to Parliament for the provision of the health service in England”.
	The noble Lord, Lord Mawhinney, a previous Conservative Health Minister, said in our debate that everyone now knew that the,
	“Secretary of State is the boss and is held accountable”.—[ Official Report , 8/2/12; col. 303.]
	I certainly hoped that this meant that in spite of the determination to transform the NHS into a regulated but independent competitive industry, the personal statutory accountability would prevent the most harmful results that we feared from the Act. I was wrong. Now I can only hope that the present damaging crisis may suggest to Ministers that they should exercise greater responsibility and accountability, not just for expenditure but for at least some of the policies proposed in the forward view.
	I want to focus in my remarks on paragraph 3 of that report, which says:
	“The future health of millions of children, the sustainability of the NHS, and the economic prosperity of Britain all now depend on a radical upgrade in prevention and public health”.
	I certainly accept that clarion call; my concern is that the 2012 Act has made it difficult to fulfil. Noble Lords will be aware that public health programmes are often rooted in community-based, sometimes voluntary organisations. These can be very useful, particularly when informal outreach schemes dealing, for example, with problems such as drug or alcohol abuse, can be much more successful than statutory services. but today the competitive reorganisation has led to a hugely expanded pool of non-NHS community providers—a staggering 69% of the new contracts agreed. In my estimation, that must lead to enormous fragmentation and great difficulty in achieving national goals.
	In particular, I draw noble Lords’ attention to very real problems in delivering good sexual health and HIV prevention and treatment services under this new system. In recent months, as the noble Lord, Lord Fowler, has just done, we have rightly focused on the Ebola virus, but the latest figures for HIV in this country are a cause for a new concern. In the past 12 months, the numbers of gay men newly diagnosed are the highest since the figures were first collected 20 years ago. During the intervening years, of course, we have developed world-leading clinical care in this complex field and created much-admired prevention programmes, but those are now threatened. Part of the problem is that the public health commissioners in local authorities simply do not have the relevant specialist knowledge and experience. I have learnt, for example, of a particularly stark case in Chester, where the hospital-based specialty services created and led by a very senior consultant are to be replaced by a consortium of GPs. There the Countess Of Chester Hospital put forward a comprehensive tender for an integrated
	sexual health service led by five consultant doctors costing £2.4 million. This has been rejected in favour of an exclusively GP service with no hospital specialist input, costing £2.8 million. It is very hard to see any financial or clinical logic behind this. I wish it was just one example, but it is not.
	I want also to explain my concern about the particularly bad situation in relation to HIV prevention. The Government have now said that the programme for national HIV health education will be cut by a staggering 50% in the next financial year. We cannot afford complacently to allow the prevention and treatment of infectious, dangerous diseases to slip from the effective grasp of a national health service. I fear that that is likely to happen.
	Overall, I would like to be optimistic about the future. I agree with many of the ambitions in the Five Year Forward View and respect Simon Stevens, who was a special adviser when I was a Minister in the Department of Health. However, he is far too complacent about the encroachment of independent advisers and the resulting fragmentation of important services. Overall, we must retain the national leadership of the NHS not only through the executive managers but essentially through the Secretary of State. His accountability to Parliament and responsibility for the provision of health services should always be the keystone of the health service.

Baroness Barker: My Lords, I, too, thank the noble Lord, Lord Turnberg, for giving us the opportunity to discuss these matters today. He, like a number of other noble Lords, is a veteran of such discussions. While I pray in aid documents such as that produced by the Royal Commission on Long-Term Care, the Wanless report, Wanless II, the Darzi report and now the Five Year ForwardView by Simon Stevens, he will perhaps agree with me that, over the time that he and I have been Members of this House, the issues facing the National Health Service have not changed but have remained the same. We have had report after report telling us in varying degrees of detail what the shortcomings of the National Health Service are, how it does not integrate with a sufficiently unbroken social care system and what it needs to do to put that right.
	My right honourable friends in another place, Norman Lamb and Paul Burstow, have similarly followed those discussions. I am pleased to say that, in their time in government, they have enacted quite a number of the recommendations put forward, not least the return of public health to local government. Back in the time of Derek Wanless, the observation was made that if our tax-funded National Health Service was to endure, it would have to do so in the context of a population that was informed and engaged about its own health, and that the NHS could not tackle that on its own. I hope that any future Government, tempted as they no doubt will be to rearrange the service—let us call it not a top-down reorganisation but a rearrangement—will resist the temptation to take public health back from local government and will leave it where it is, with the health and well-being boards, to give them the chance to build on the work they have done on prevention in
	the past two years. Some 70% of the health service is now about enabling people to manage long-term conditions.
	It occurred to me—particularly in the past week, when we have been inundated with stories about how the NHS is failing to deal with emergencies—that much of the literature on the NHS is directed at how we deal with an ageing population. At the same time, we have rather lost sight of how young people engage with the NHS. The most interesting findings over the past month or so concerning the problems in A&E were not about lots of older people who are no longer being supported by social care turning up inappropriately in accident and emergency units but rather the number of young people who turn to accident and emergency units as opposed to their GPs. That is a very worrying issue to which we should give great thought, because GPs continue to be the linchpin in terms of most people’s ability to manage their own healthcare and their health and well-being in the longer term. If young people are engaging only with A&E on an episodic basis, that will store up problems for the NHS in the longer term.
	Finally, one of the most laudable things that has happened in the past two years is the increased attention that this Government have given to mental health, which is supported by the Opposition. We are finally beginning to understand the importance of mental health and the problems that we cause the country in the longer term if we ignore it. Some interesting work has been done by new organisations which have not previously taken any part in our health debate, such as Mumsnet, which has talked for the first time about the incidence of mental health problems in very young people aged under 11. It also talks about the high incidence of perinatal mental health problems beginning to challenge orthodox providers in the National Health Service and the voluntary sector. I sincerely hope that the next Government will continue to work with organisations, perhaps new and emerging voluntary providers, to take a completely fresh look at some of the long-standing problems that we know have challenged the NHS.
	We as a party have said that we will aim to increase NHS funding by £8 billion. We will do so on the basis of continuing challenge and reform. It is possible for there to be a 25% reduction in preventable mortality by 2025, but only if we continue to change the way in which the NHS interacts with the population, the voluntary sector and the people who are capable of addressing the problems upstream that present as emergencies to the NHS.

Baroness Masham of Ilton: My Lords, I thank the noble Lord, Lord Turnberg, for securing this very timely debate. The National Health Service is so important that it should not become a political football. Patients need accurate, safe healthcare to enable them to get better quickly. If that is not possible, they should have compassionate care. All services need to co-operate and communicate with patients. Integration should be the aim, not working in silos.
	I give myself as an example. I had been coughing for months and had an X-ray on 21 November but
	have never had the result. Having had three antibiotics, I decided to come off the statin that I was taking as I became frustrated with the cough. It seems to have worked. So much of patient care seems to be trial and error.
	I take this opportunity to stress some of the difficulties surrounding rural health. Our surgery at Masham is open only every other Saturday for half an hour, for a half day on Thursday and is closed every day between 12.30 pm and 2 pm. The surgery needs to be improved but no one will pay, so my doctor went to Canada.
	Next door to the surgery is the Marsden pharmacy, which has a four-inch step with no handrail or ramp, making it inaccessible for people using wheelchairs unless they are super-fit, and for those using walking frames. It is frustrating that this building has just been renovated and disabled peopled, who perhaps need the pharmacy more than most, have not been considered.
	On Sunday, I spoke with a member of the Army from Catterick, which has the largest military camp in Europe. I was told that the Catterick Medical Centre has been given a bad report and has to close every day at 3.30 pm, leaving the A&E department at the Friarage Hospital as the only alternative. More military personnel are coming back from Afghanistan and Germany. Therefore, urgent improvements are needed if the future of the NHS is to improve.
	I was very pleased to be invited to give the awards to the Yorkshire Ambulance Service last autumn. I found the staff to be dedicated and enthusiastic. In rural areas, where the countryside can be challenging and public transport in some areas is non-existent, the ambulance service can be vital. Without doubt, the Air Ambulance is the most popular charity in north Yorkshire. The impact on the ambulance services in England is very great. There continues to be a year-on-year increase in demand. The major increase has been seen in top-level emergency calls.
	There is a worrying situation in that there is a shortage of district nurses, with many having retired or gone off sick. They are so important in helping with ill and disabled people in the community. What plans are there to increase the numbers in the future? I have a cousin married to a registrar surgeon. The surgeon tells me that there is concern about the modern shape of training for surgeons. She tells me that hospitals with poor records should not be training and that sometimes deaneries come round and find poor standards but do nothing about it. She also tells me that the European working time directive has not helped with the training of surgeons. Surgical training should be a priority. I ask the Minister: should we not be aiming for the highest standards of surgery and safety, and stop the worrying increase in negligence claims that is draining the NHS?
	I am so pleased to see my colleague, the noble Baroness, Lady Wilkins, back in her place. As president of the Spinal Injuries Association, I ask the Minister to look into the worrying situation where so many excellent doctors and surgeons working in spinal injuries have retired and new young doctors are not coming forward to take their place. Also, the cutting of physiotherapists and occupational therapists is detrimental to rehabilitation. High-lesion tetraplegics on respirators
	are often kept in intensive care beds in general hospitals because of the lack of beds in spinal units. Therefore, there is a blockage in intensive beds in general hospitals, causing huge problems.
	Because of paralysis, the “three Bs”—bowels, bladders and bedsores—become very important to these patients. One of the distressing problems for spinal patients being in general hospitals is the difficulty of having their bowels evacuated, as nurses seem to shun this essential part of care. I hope that in future the NHS will recognise the importance of specialised spinal units with trained specialist staff.
	I end by saying that there are many complicated conditions that need to be researched, but of concern is the increase in people with liver disease and hepatitis C. I hope that in future they will get the new, crucial drugs that are available but not yet approved by NICE.

Lord Rea: My Lords, I am sorry that we are missing a contribution from the noble Lord, Lord Ribeiro. He is always worth listening to. I hope that being scratched from the debate does not mean that he is unwell.
	I thank my noble friend for bringing up this wide but highly topical subject, given the daily headlines about one NHS crisis or another, including today. The issue is also high on the agenda of all parties in the run-up to the election. What is becoming increasingly clear—my noble friend Lord Turnberg referred to this—is that the NHS and social care are underfunded and that this is the main reason for longer waiting times and deteriorating services. To call for greater efficiency in a health service that is recognised internationally as highly cost-effective can only mean staff reductions or lower salaries, and worse care. Some say that this is deliberate to encourage more people to move to private medicine.
	I want to focus on prevention, which is highly relevant to today’s pressures, as described in the Five Year Forward View, to which several noble Lords have referred. It is better written than the average document from the Department of Health and freer of jargon and acronyms, although I noticed one or two lapses—for example,
	“the need to transition to a more sustainable model of care”.
	The report puts prevention of disease high on the agenda in the section headed, “Getting serious about prevention”. This phrase is taken from the health review written by Derek Wanless 14 years ago. At this point, I should declare an interest as trustee of the UK Health Forum, formerly the National Heart Forum, which advised Wanless when he was writing his report. He suggested, as the noble Baroness, Lady Barker, said, “a fully engaged scenario”, in which all sections of society should become aware of the health implications of their activities and products. He warned that unless the country took prevention seriously, we would be faced with a sharply rising burden of avoidable illness. As the Forward View put it,
	“that warning has not been heeded—and the NHS is on the hook for the consequences”.
	Instead, one in five adults still smokes, a third of people drink too much alcohol or do not take enough exercise and almost two-thirds are overweight or obese. This has had consequences in increasing the flow of costly treatments.
	Our expectation of life, however, continues to go up. Part of this is due to the success achieved in reducing cigarette consumption, partly due to the measures introduced by the last Government, including banning tobacco advertising. This Government have also brought in some tobacco control measures but, rather worryingly, they seem to be dragging their feet on the important issue of plain packaging. It is important to get this legislation on to the statute book before the election and to do that it must be laid before Parliament before the end of this month or sooner. I think that the noble Earl is aware of the widespread desire from across the health professions and elsewhere for this to be done. I hope that he will be able to assure the House, perhaps today, that this legislation will reach the statute book before the election. If not, the Government and the Conservative Party will lose even more credibility when they claim to safeguard the nation’s health.
	The NHS should also take some credit for the continuing increase in life expectancy, but the increasing incidence and prevalence of avoidable non-communicable disease is a major cause of the heavy pressure that the NHS is now under. One example of this is the avoidable burden that heavy drinking places on A&E departments at weekends. The Government have not taken the first step in reducing alcohol consumption that minimum pricing would provide. There is little doubt that the drinks industry is putting pressure on the Government to avoid this simple measure. It would have most impact on cut-price off-sales, which many young people indulge in, “preloading” to avoid higher bar prices when having a night out. In the past few days, the alcohol health association has said that there should be more information on alcohol products, giving not only the strength but the calories and other health implications.
	The Five Year Forward View puts it rather admirably:
	“We do not have to accept this rising burden of ill health driven by our lifestyles, patterned by deprivation and other social and economic influences. Public Health England’s new strategy sets out priorities for tackling obesity, smoking and harmful drinking; ensuring that children get the best start in life; and that we reduce the risk of dementia through tackling lifestyle risks, amongst other national health goals ... While the health service certainly can’t do everything that’s needed by itself, it can and should … become a more activist agent of health-related social change”.

Baroness Thomas of Winchester: My Lords, belatedly all political parties are waking up to the fact that the future of the NHS is top of most people’s agendas in this country, which is why it is going to be prominent in all manifestos for the coming election. The country is also recognising that not only is the population getting older, needier and more disabled but disabled people like me are living longer than we probably would have done some time ago. Boys and young men with Duchenne muscular dystrophy only
	15 years ago were dying in their teens, yet today, thanks largely to night-time ventilation, they are living into their 30s and 40s.
	The lessons in the field of rare neuromuscular conditions—the field that I know best—are clear. Money spent wisely now by commissioners on access to specialist support and better care in the community for people with these conditions will save a significant sum later in unplanned emergency hospital admissions. That was the finding of a 2011 audit by Professor Michael Hanna of the National Hospital for Neurology and Neurosurgery in Queen Square, yet it appears that commissioners are not prepared to invest in this way to save in the future. I count myself lucky that I live in the capital, near a centre of excellence in this field, but there are significant gaps around the country in specialist care. The ideal is the development of managed clinical neuromuscular networks that bring together consultants, physiotherapists and family care advisers. An example is the one in the south-west, which co-ordinates service provision and the sharing of skills and expertise.
	I now turn to research, which was a hugely important but largely unrecognised part of the Health and Social Care Act: the Act places a duty on the NHS, for the first time in statute, to promote research. A future NHS must do more to promote research and ensure that the UK has the clinical trials infrastructure to attract investment from pharmaceutical companies wishing to conduct trials. That was mentioned also by the noble Lord, Lord Turnberg. With the right support, the UK could become a world leader in this field—for example, through support for patient registries and databases for rare diseases. At present, the Muscular Dystrophy Campaign funds the NorthStar database and the national neuromuscular database, but this arrangement does not guarantee long-term security. Does my noble friend agree that if the NHS is to promote research, it should provide support to databases and registries for rare diseases?
	I now turn briefly to funding for new treatments. The NHS will face an increasing challenge to deliver innovative but high-cost treatments with advances in genetic medicine. Will increased competition for funds mean that treatments for rare diseases lose out? To avoid that situation, will the Government introduce a ring-fenced fund for rare disease drugs, as has been done in Scotland?
	That brings me to my last point, which is that the NHS must have a clear and transparent means of approving new treatments. I am sorry to say that the experience of the Duchenne treatment Translarna does not bode well, with one of the final stages of the process being held up. I know that my noble friend’s colleague, the Minister for Life Sciences, has been closely involved in helping to find a solution. Will my noble friend encourage his colleague to redouble his efforts to help steer through an interim solution that would allow patients access to this drug, which is available in Europe, by April of this year? It is effective only in boys who can still walk. There are many parents who watch in despair while the days pass, knowing that without a drug such as Translarna eventually their young sons will take their last steps.

Baroness Cumberlege: My Lords, my interests are in the House of Lords register but I should declare that I am executive director of Cumberlege Connections and of Cumberlege Eden & Partners.
	I, too, congratulate the noble Lord, Lord Turnberg, on initiating this debate. He is a truly remarkable man and is probably one of the most qualified and experienced of your Lordships when it comes to analysing the health service, as was evidenced today in his remarkable speech. I did not agree with it all, but it was remarkable. If one looks further, it is really interesting and fascinating to read his book, Forks in the Road. Does not that title really sum up the views of the nation? The NHS is hugely valued. We are at one in wanting to ensure its future. We are journeying on the same road, but there are many choices to be made on the way.
	The ethic is inalienable. Whether we are rich, poor, young, old, black or white, we want a service that is largely funded by the taxpayer. I say largely because successive Governments, including the Labour Party when it was in government, have largely eroded the ethic by stealth—introducing prescription charges and other charges. The general public do not want to produce a credit card for services rendered but they are ambivalent as to who provides the service. If the service is compassionate, kind, professional, efficient and provides value for money, albeit that it is provided independently, the public are largely satisfied.
	I endorse the views of my noble friend Lord Horam. Worldwide the NHS is recognised as a winner. We have been ranked as the top health system in the world by the Commonwealth Fund. We also know that when it comes to asking the British what makes them proud to be British, the NHS is top of the list, before the Armed Forces and even the Royal Family. We also know that there is always room for improvement. Lest we get complacent, we only have to think of North Staffordshire, Winterbourne View and so on.
	The noble Lord rightly highlighted the challenges that we face and they are beyond dispute, but we should not ignore the progress that we have made. At a time of austerity, we have increased the NHS budget by £12.7 billion. “Not enough”, is the cry but it will never be enough. In the past five years, the number of clinical staff has increased by 12,500, and 850,000 more operations are being delivered each year compared with 2010. The number of patients looked after in mixed-sex wards is down by 98%, which is a subject I know is very close to the heart of the noble Baroness, Lady Jay, from when she was in opposition and when she was in government. Listening to her speech today, I was deeply worried when she quoted the shadow Health Minister as saying that he did not understand how the current system works. I respectfully suggest that he looks at pages 88 and 89 of the book by the noble Lord, Lord Turnberg, which clearly sets that out in a diagram.
	Looking at the next five years, as has been said, NHS England’s priority is to engineer a radical upgrade in prevention and public health. It goes on to say that the NHS will,
	“back hard-hitting national action on obesity, smoking, alcohol and other … health risks”,
	which I welcome. I share the view of my noble friend Lady Barker that we should stay with the health and well-being boards, and not be tempted for another reorganisation.
	In Britain, we attempt to run a fair society, a society which protects citizens from abuse by those unwilling to respect others. We have cracked down on drunken or reckless drivers and on faulty cars. People who abuse our roads are prosecuted and our roads are safer for it. The problems of the NHS are in some measure due to people abusing the system. Resources are spent on dealing with drunks, time-wasters and drug misusers, leaving the system in danger of being overwhelmed so that those in real need are deprived of life-saving treatment. The NHS constitution is very strong on rules for staff but is ineffective and weak when dealing with users. The contrast with drivers who have to learn and adhere to the law is very stark.
	Looking to the future, we have to introduce rules to protect and enhance the treatment of people who are ill. Without known rules, any organisation, including this House, can descend into chaos. With a strong economy, we can afford to pay for its use but we should not fund its abuse. Does my noble friend agree?

Lord Liddle: My Lords, I, too, congratulate the noble Lord, Lord Turnberg, on the way in which he introduced this debate. It has been a civilised and, in many respects, expert debate. I am worried that I may lower the tone because I want to make a couple of more political comments. However, I shall try to do so in a civilised way.
	The basic reason I wanted to speak in this debate is that I fear for the future of the National Health Service given the implications of the emerging Conservative approach to public finance in the next Parliament. I do not in any way doubt the sincerity of Members opposite—my friend the noble Lord, Lord Horam, the noble Baroness, Lady Cumberlege, who has just spoken, and the Minister—the Secretary of State for Health or the Prime Minister, or their commitment to the principle of the National Health Service. However, I doubt the sustainability of that commitment given the approach to public finance set out in the pre-Budget report at the beginning of December, particularly the prioritisation of tax cuts when resources become available and the intention to reduce by the end of the next Parliament the share of public expenditure in GDP to 35%.
	The Government have done their best in this Parliament, in their way—I congratulate them on that—to maintain NHS spending in real terms, which, given the financial pressures on the country, was a good thing to do. That has worked for a while. The previous Government increased spending on the NHS a great deal. There were productivity gains to be made from that increase in spending and we have continued to see outcomes improving in the present Parliament.
	However, the strains are now beginning to show. We know that, because of the increase in population, NHS spending per head is falling. Simon Stevens’s five-year analysis—I confess to being an admirer and
	friend, having worked with him—is brilliant. It demonstrates that there is a large potential funding gap unless, as the noble Lord, Lord Horam, pointed out, it can be closed by a more rapid rate of efficiency gain. With respect to the noble Lord, that will be difficult to achieve in a highly labour-intensive service. It is not like private sector manufacturing. This is a highly labour-intensive activity and 3% efficiency gains will be very difficult to achieve. So we will need additional investment.
	As to what will happen to the rest of the public sector under this public spending outlook in the next few years, we will see severe austerity in welfare and public services, as set out in the pre-Budget report; more strain on poor families; a continuation of inadequate supply of social housing; weaker children’s services unable to protect children at risk; a narrower school curriculum because schools cannot afford to teach more broadly; and local authorities unable to meet the needs of all but very needy people in adult social care.
	What will be the consequence of all this? Every academic and expert in public health tells us that if there is an increase in poverty, ignorance, bad housing and social neglect, what we will get is more pressure and problems for the National Health Service. On a holistic view of public spending, the Government’s plans are flawed and we need a more sustainable position. So I congratulate my party on at least indicating what it will do in the first year of the next Parliament in terms of extra spending and how it will be paid for.
	Finally, we need cross-party debate and consensus on a long-term funding model for the NHS. I firmly support Frank Field’s ideas for a broadly based hypothecated tax that would take the funding issue out of politics and enable managers in the NHS to plan ahead for a more efficient service.

Lord Kakkar: My Lords, I join in thanking the noble Lord, Lord Turnberg, for securing this important debate, and in so doing I declare my own interests as professor of surgery at University College London, consultant surgeon at University College London Hospitals NHS Foundation Trust, and chairman of University College London Partners, our academic health science centre and network.
	It is striking that in 1948, some 48% of the population failed to reach the age of 65. Recently it was calculated that only 18% of the population would fail to do so. That is a remarkable manifestation of how important universal access to free healthcare has been in securing the health prospects of our fellow citizens. It is also striking that by 2025, it is estimated that 18 million of our fellow citizens will be living with a long-term chronic condition. With an ageing population and all that chronic disease, it is inevitable that there will be increasing demands on the facilities and resources available for the provision of healthcare. Indeed, we have seen in recent weeks increasing demands being made on accident and emergency services. The Nuffield Trust recently published a report which estimates that by 2022, if the current changes in demographics with an ageing population and the present growth in demand is maintained on a similar trajectory, we will need to
	provide 6.2 million extra bed days a year, which equates to some 17,000 extra hospital beds, the equivalent of 22 new 800-bed hospitals. It is therefore important that the noble Lord has tabled this debate about the future of the NHS because we must ask how we will address this increase in demand.
	We have also heard that it is not only about an increase in demand. Quite rightly, it is about an increase in expectation. That is because in the United Kingdom we pride ourselves on having invested substantially in a strong science and research base and in biomedical research. Much of that investment is taxpayer-funded, and it is therefore absolutely right that our fellow citizens expect to see the benefits of that research applied to improvements in healthcare and the provision of better long-term prospects for a healthy life long into old age.
	The noble Baroness, Lady Cumberlege, mentioned the recent US Commonwealth Fund report grading 11 different healthcare systems. Ten healthcare systems from around the world are compared to the United States system, and once again, for 2013, the NHS ranks number one for the quality of care—that is, the efficiency of care, the safety of care, patient-centred care and the co-ordination of care. Interestingly, however, we rank 10th out of the 11 nations in providing healthy lives for our citizens. So there is more to do to deliver effective healthcare and, in this regard, as has been noted in the debate, it is important to pay attention to the NHS England Five Year Forward View. Quite clearly, the funding models described in that Five Year Forward View expect some degree of efficiency gain further to the substantial gains that have been achieved during the lifetime of this Parliament. What assessment have Her Majesty’s Government made of how much of that additional gain in efficiency will be derived through the application of innovative therapies and interventions as well as innovative models for the delivery of care?
	In this regard, it is particularly important to take note of the announcement made yesterday by NHS England of the national Innovation Accelerator programme and of the appointment of the new national director of new models of care. In this regard, I emphasise my declaration of interest as chairman of UCL Partners, as UCL Partners is the host for the national Innovation Accelerator programme, which is being supported by NHS England and the Health Foundation.
	There is no doubt that innovation plays, and has played in recent years, an important role in the delivery of healthcare. What assessment has been made of the emphasis on the adoption of innovation, for instance the approach towards telemedicine? What progress has been made in providing telemedicine solutions to the management of chronic long-term conditions for the 3 million people living with long-term conditions that it is anticipated would be covered through these new strategies by 2017?
	In addition, of course, there has been great emphasis on the whole area of personalised medicine, and the announcement of the 100,000 genome mapping programme. Again, I wonder whether the noble Earl could comment on how much progress has been made
	in that regard. How much progress also has been made in respect of the UK Biobank and the development of a national health and informatics strategy combining data from all of those to provide a very strong basis for improving health outcomes and driving improved healthcare for our fellow citizens?
	The challenge for improved workforce planning will also need to be addressed. As part of changes introduced in the Health and Social Care Act 2012, Health Education England was to take an important role in ensuring that local needs for the provision of healthcare—understanding the local needs of local populations—would better drive workforce planning. Is the noble Earl content that that journey has begun and that Health Education England is able to perform in that way?
	Finally, great emphasis was put on the need to develop clinical leadership. In this regard, I wonder what assessment has been made of the NHS Leadership Academy and when we might see the report of the noble Lord, Lord Rose of Monewden, and his assessment of how leadership in the NHS might be improved to ensure a greater chance of our achieving the goals that we all share.

Baroness Wilkins: My Lords, I thank my noble friend Lord Turnberg for securing this debate. I want to concentrate on the future of the spinal cord injuries unit. I declare an interest, having been spinal cord injured at university in the 1960s. Last year, I returned to the national spinal injuries centre at Stoke Mandeville Hospital to do four months of unsolicited in-patient research, having broken both my legs. The scene is depressing. I found that the speciality in which we led the world is pinched and demoralised. The result is a pointless waste of NHS money as well as of precious lives. Even in this sorry state, the relief to have been found a bed there after 10 days in a general hospital was overwhelming. I cannot thank the noble Earl and my noble friends enough for all their appeals to secure me that bed. Such help should not be necessary, but I will be undyingly grateful.
	It is tragic that the demand for the spinal injury service far outstrips the supply, yet bed numbers have been and continue to be cut, leaving newly injured people in district general hospitals. Twelve spinal beds at Stoke have been changed to general use since September 2013 and, despite continual assurances, have still not been returned. Nationally, as of 6 January, 151 newly injured people that we know of are being treated in general hospitals by non-specialist staff, at the risk of developing complications such as urinary tract infections, pressure sores and psychological difficulties. The most vulnerable patients are those high-level tetraplegics who need ventilation to assist with their breathing. Currently, 19 ventilated patients are waiting to be admitted to specialist care, with an average waiting time of six weeks. Their intensive care beds cost around £1,500 per night, 50% more than a ventilated bed in a spinal unit.
	Delayed discharges badly frustrate the optimal use of spinal units. The situation at the Salisbury Odstock spinal unit is not unusual. One patient has been awaiting
	discharge for more than two years, and another for more than a year. They are occupying spinal beds that cost £500 to £600 a night. We know that the drastic cuts to social care and the appalling lack of accessible housing have caused bed-blocking but, as I found, so has the intransigence of the CCGs. To protect their own budgets, CCGs refuse to accept the spinal centres’ advice and insist on their own assessments when the patient is almost ready for discharge. A completely unnecessary delay then ensues in organising care packages and essential equipment. In some parts of the country the local CCG will not even take the unit’s advice on providing the appropriate wheelchair. Instead, a patient has to be transported, with an escort, to their local wheelchair centre, with all the costs that that involves. As a result, there are considerable delays and in some cases rehabilitated patients have even been discharged home on stretchers to wait for a wheelchair at home—what a waste.
	The situation with delayed discharges has now reached such a critical level that the All-Party Group on Spinal Cord Injury is about to conduct an inquiry into the causes and to make recommendations. I ask the Minister, first, to support that inquiry and, secondly, who now is in a position to be able to do something about this? The spinal centres have no power to compel the CCGs to address these issues; neither, it appears, does NHS England.
	NHS England directly finances spinal injury as a specialism but the money is not ring-fenced. The centres will tell you that up to half their budget is absorbed by their host trust before it reaches them. Would it not be better if the NHS funding went direct to the spinal centre, which could then pay the host hospital for the services it uses?
	Underlying all these issues is a general downgrading of spinal cord injury as a specialism in its own right, which must have Ludwig Guttmann turning in his grave. Currently there are consultant vacancies right across the service due to the lack of suitable candidates. Sadly, once we aligned our specialist medical training with Europe, spinal cord injury became part of the medical specialism of rehabilitation rather than a specialism in its own right. There appears to be no clear mechanism to ensure sufficient numbers of spinal consultants or adequate nursing staff and therapists to meet the need. Is anything being done to change this?
	At Stoke Mandeville the trust has merged the spinal unit into a specialised services directorate along with haematology, pathology, sexual health and miscellaneous others. As a result, the spinal unit is managed by senior managers who have no knowledge or experience of working with spinal cord injury. I found that the staff feel neither valued nor supported. As a result, key staff have left, with the loss of their invaluable specialist knowledge, skills and expertise. When we have such a shortage of staff, surely it is vital to retain the ones we have.
	Finally, whichever party wins the general election, will the new Government recognise that our world leadership role in this area of specialist medicine is now being sacrificed because the management of the
	service is driven by concern with local issues? Will they develop a strategic vision once again to keep the UK in the forefront of the care, treatment and rehabilitation of people with spinal cord injuries?

Lord Cormack: My Lords, it is a pleasure to follow the noble Baroness. How good it is to have her back among us. She is a testimony to the care that she has received. It is good for her to remind us of some of the problems that are faced by those who have to undergo spinal surgery.
	I begin my remarks by referring to the noble Lord, Lord Liddle, because he ended with a plea for consensus and for taking the NHS out of party politics, and I endorse that entirely. He also made clear how important and central funding is. That is the issue.
	Let us remind ourselves that the health service is, in effect, via Beveridge, the product of a grand coalition. Whether we will ever have a grand coalition like that again, I do not know; I certainly hope that we will never have the war that created it. However, it may be that the strange results in June could make that an infinitely preferable solution to the SNP holding the balance of power—but I must not digress because I wish to say that we are not serving the interests of the country or the health service by bandying about words such as “privatisation” and “weaponisation”. We have to focus on the service, what it needs and the funding it needs, and there has to be—I have said this many times in this House and in another place—a plurality of funding.
	When I entered the other place in 1970, I did not have a single constituent with an artificial hip or an artificial knee, let alone a transplanted heart. By the time I left, 40 years later, the situation was very different. When I first entered the other place, I used to write a letter to every 18 year-old coming of age, and I used to write a letter to every 80 year-old, because it was quite an achievement in those days to reach the age of 80. I could not have done that in 2010. That is really the underlying problem. We are living longer, we have far better medical techniques, drugs and cures, and we are still relying on a single funding base.
	I would like to see a commission set up after the election—Frank Field would be an ideal chairman—to look at funding and to rule nothing out. We have charges at the moment for prescriptions for certain people. Many GPs of my acquaintance say that it would cut down the absent rate—people who do not turn up for their appointments—if we charged for them. We could have a charge for those who are in hospital if they are in full-time employment. I quite like the Field idea of a hypothecated tax. We could have £1 on every bottle of alcohol and 50p on every packet of cigarettes devoted specifically, absolutely and totally to the NHS. We could have a system, as other countries do, of obligatory insurance. I am not particularly commending any individual one of these remedies, but I am saying that there are many alternatives.
	The noble Lord, Lord Turnberg, who introduced this debate very splendidly, made the point that there has to be—he did not use the words—a plurality of funding, and there does. We should have a commission
	under a respected figure—and I believe that it would be entirely right that that respected figure should come from the left of the political spectrum. I do not believe that the Labour Party can for a moment claim entire credit for the National Health Service—of course it cannot—and I am proud of what Conservative Governments have done, but it was brought into being under a Labour Government and I see no reason why a respected figure whom we could all trust could not chair such a body, which would be broadly representative, to look at these alternatives, ruling absolutely nothing out.
	Another thing that we should look at is what treatments are properly available under the National Health Service. If somebody is smashed up in a car crash, of course plastic surgery should be available on the NHS without any charge—but should a man or woman be allowed to change their shape through plastic surgery on the NHS? No. We have to look at a whole range of things, and we have to say what is appropriate for a world-class National Health Service to deliver to all people and how we contribute best to it.
	After all, we all do contribute to it through our taxes—those of us who pay taxes, and the vast majority of us do. If there are additional charges here or there, and if there is a hypothecated tax such as Mr Field has recommended and the noble Lord, Lord Liddle, has endorsed, that is fine, but let us get this out of the petty party-political arena. Health is of supreme importance to all of us. There is no politician in any party who is not sincerely dedicated to the health of the people—of course there is not. Let us accept, as the noble Lord, Lord Liddle, said, the absolute integrity and sincerity of those on all sides of the political spectrum. Let us say that funding is the fundamental issue and let us try to get a consensual answer to the problems to which I have alluded.

Lord Desai: My Lords, it is a great pleasure to follow the noble Lord, because he has taken the discussion in the direction that I wanted to take it. I start by saying that the NHS is a miracle; it has a great staff. It works by consensus, but, as Lord Bauer, who was here some years ago, used to say, the more we are similar, the more we exaggerate our differences. The differences that we have over the NHS are actually very small, but it pays us politically to exaggerate how large they are. For as long as I have lived here and taken part in debates on the NHS, it has always been in crisis. I do not remember a single debate in which everybody said, “Isn’t it great? Things are fine. Everybody is happy. Nurses’ and GPs’ morale is no longer shattered”. It never works like that. We can live with this miracle only by being dissatisfied with it constantly.
	There will always be the cliff-hanger idea that there is not enough money. There is absolutely no way of having enough money in a zero-price service which will not generate excess demand. That is not even elementary economics. If you do not know it, you should not be allowed even to enter a course of economics.
	But we have still managed. We have managed to finance the NHS by and large from a single source of funds—although there are peripheral aspects. One problem will be—and this is not a matter of who wins
	the next election—that there will no longer be the kind of money there was. As I have said in other contexts, we are about to enter a low-growth period for the next 10 or 15 years, and the good times are over. They are not going to come back—this is nothing to do with me, nothing to do with the Labour Party and nothing to do with the Conservative Party—so we will have to think of smart ways of meeting the needs that we will have. Not only is the NHS a zero-price service but the types of demand that it faces are proliferating. People are not only living longer but they want a better quality of life, a better shape and things like that—and then we have to address new problems, for example in mental health.
	Let me concentrate on one big lacuna that I see in the system. The system does not ask consumers to do enough. We provide them with a zero-price service, but, in return, the consumer does nothing. The consumer is not asked to look after his or her health, to cultivate good habits of not drinking too much or not smoking too much, or whatever it is. The consumer expects, upon presenting himself or herself, to be treated. In any zero-price industry and with any zero-price commodity, if you are not going to allocate resources by price, there has to be something else to ration, and the rationing that we use is time. Waiting time is one rationing device that we use. As we have seen from recent coverage of the A&E crisis, people feel that if they are asked to wait for hours, it is the end of the world. They should have gone to their GP, as the noble Baroness, Lady Barker, said, but going to their GP is too much of a hassle, so they suddenly present themselves at the cheap option, A&E. But if you have to wait, you should accept the price because you did not invest the time in going to your GP. You think this is cheaper? It is not. You have to pay in extra time.
	One thing I have advocated off and on is that patients ought to be made aware of how much things cost. They should not be charged but they should be made aware of the shadow price of the things they get, especially the things they waste. If they do not turn up for an appointment, they should be told what it costs. For a long time, I have advocated that we should give each person a shadow budget per head of NHS spend—perhaps £1,500 or 1,500 points. Every time you go to a GP or anywhere, you have a little Oyster card and it deducts so many points from that amount. You do not have to pay but you will be made aware at the end of the year by getting an account of how you spent your 1,500 points.
	People ought to be made aware that these things have different prices. If we can make them at all aware of this, it might change their behaviour. We will need not only more productivity but better behaviour from consumers. We will all have to economise. We cannot let the consumer out of the need to economise to get a better health service. I do not have time to say much more than that, but I hope that if we can change behaviour with shadow pricing in the National Health Service, we will have taken a great step forward.

Lord Morris of Handsworth: My Lords, I, too, commend the noble Lord, Lord Turnberg, for securing this important and timely debate. Like other
	noble Lords, I also come to the debate as a long-term user of the NHS, but one who fears for its future as I see the most tried and trusted institution disappearing almost daily in terms of its ethics, values and what it stood for.
	In 2006, the current Prime Minister told us that the NHS would be safe in his hands. He promised that there would be no more pointless, top-down, disruptive reorganisation and that changes would be driven by the wishes and needs of NHS professionals and patients. As a matter of fact, this Prime Minister has presided over the biggest, most costly and I would say pointless reorganisation in the entire history of the NHS. Patients and professionals alike have personally experienced the results of this destructive reorganisation which the majority neither wanted nor needed. No Conservative or Liberal Democrat manifesto contained any mention of this approach, nor was it mentioned in the coalition agreement.
	Last October, the CQC report described some A&E departments and maternity units as so short of doctors and nurses that they posed a danger to patients. NHS staff are leaving the profession feeling undervalued, underpaid, overworked and not consulted. The result of this mass exodus means that last year the NHS spent £1.3 billion on agency and contract staff.
	Let’s face it. This has been one of the worst weeks in the history of the NHS. Day after day we have heard that one health authority after another is unable to cope with patient numbers, with waiting times increasing, operations postponed, staff demoralised, ambulance services under pressure and many operating below mandatory levels. People are urged to use A&E departments for genuine emergencies only, yet many have been unable to get a GP appointment. As a nation, we are of course living longer. The official statistics show that over the course of the past few years more than 700,000 elderly people have blocked hospital beds because a care home or a support home could not be found to accommodate them.
	Throughout the world, the NHS has been admired and even envied for its record in providing healthcare to people when they need it most—publicly owned, publicly funded, publicly respected and publicly accountable. However, the NHS is becoming unrecognisable. I am not alone in fearing for its future. The British people want an NHS dedicated to making a difference rather than a profit; a service which belongs to the people and which is not for sale. I want the workers to be properly represented in the decision-making process, properly remunerated and consulted about how the service is run and delivered.
	I, for one, look forward to the British people having the opportunity to rescue the National Health Service and hand it back to those who need it, those who use it and those who care for it.

Lord Balfe: My Lords, I congratulate the noble Lord, Lord Turnberg, on securing this debate. My first point is that we may have differences, but the National Health Service is basically safe in the hands
	of all the parties represented in this Chamber. We disagree about how we do it, but we do not disagree about the fundamental aim: to provide a health service free at the point of demand. I was very interested in what the noble Lord, Lord Desai, said. I have known him since I was at the LSE many years ago. The points that he made about a zero-price service are absolutely spot on.
	I am interested, even pleased, to hear that we are top of the world rankings. I am also surprised, having had experience for 35 years of the Belgian and French health service, that we have outranked them, because that has not been my personal experience with those two health services. None the less, I will believe it: the survey is obviously right.
	Why do I speak today? When I was at the LSE 45 years ago, I wrote my dissertation on out-of-hours GP services. Although my career moved me to a distinctly different area, that is a subject that has continued to interest me. Today, I want to speak particularly about the problems—note that I say “problems”, because I think that the word “crisis” should be used sparingly—facing the out-of-hours medical service. First, many people do not find the out-of-hours medical service easy to access. That is in part caused by the lack of GP cover. The previous Government negotiated a GP contract which, I am told, gives the average GP the highest pay and the lowest hours in the European Union.
	Evidence suggests that about 30% of patients who self-present at A&E would be better advised if they had called NHS 111 first. However, using A&E may be preferable, particularly for young working people, to trying to get an appointment with a GP. Some young and generally healthy migrant workers do not understand our medical system and do not register, so recourse to A&E is a natural consequence of unexpected illness. The out-of-hours service which exists to provide medical cover when doctors are not on duty is not widely understood.
	In Cambridge, where I live, we remember Dr Ubani, the doctor with imperfect English who, after a full week’s work, flew in from Germany to do a session of weekend cover and killed a patient through overprescription. Few people are, however, aware of the considerable steps taken to prevent such a tragedy recurring.
	Doctors’ surgeries are, for much of the time, dark and closed. A&E services have the lights on and, whatever the figures say, you will be seen swiftly if there is a life-threatening condition. If not, frankly, there is an option of settling down with a book and waiting one’s turn. This is not necessarily an unwelcome scenario, especially if the alternative is taking time off work, sometimes from a zero-hours contract, to see a GP.
	We also know that the present system of dealing with calls through the 111 service can lead to additional referrals to A&E. The 111 service is staffed by trained advisers but their training is in operating the system, not in medicine. The system has a fail-safe and evidence would seem to suggest that this can lead to more referrals. However, imagine the outcry if the system
	allowed discretion without knowledge. We would soon have an outcry, and rightly so, if there were unnecessary deaths.
	Finally, there is considerable evidence that in nursing homes and for other carers of the elderly the first manifestation of a medical issue will lead to the calling of an ambulance. This has rightly followed a lot of inquiries about failings in homes but, as a consequence, it adds to the pressure.
	It will be evident from what I have said that a stronger and earlier medical input is a crucial part of dealing with this problem. I would like the Minister to look into the following suggestions and, in due course, come back with a response. First, in Cambridgeshire the clinical commissioning group is in the process of establishing a joint emergency team that will provide integrated care covering community and hospital care, for a fixed price per person per year. This project, which begins on 1 April, will provide a round-the-clock emergency service that will work alongside ambulances and out-of-hours GPs. Will the Minister take a close look at this initiative with a view to promoting its use elsewhere? I notice that it is mentioned in the report.
	Secondly, I ask that consideration be given to integrating the 111 and out-of-hours service. Thirdly, I suggest that the introduction of a GP input into the A&E front of house or reception areas could deal quickly and effectively with some of the less serious cases. Finally, I ask the Minister to continue to look at ways to extend the hours that GP services are available. We are no longer in an economy nor do we follow lifestyles where a visit to the doctor is easy to fit in. We need to build an element of consumer choice into the provision of medicine.
	I have lived partially in Belgium for the last 35 years. It has a fully socialised medical system, not a private system, but the patient can shop around. There is patient power there at GP level, much more than in the United Kingdom. Maybe this is another European practice that is worth studying with a reference to importing more patient power into the National Health Service.

Lord Warner: My Lords, I, too, congratulate my noble friend on securing this debate at such an appropriate time. I share his analysis, particularly around what I see as the decline in the effectiveness of general practice. However, I want to focus on just two strategic issues: the FiveYear Forward View and the funding issues; and the problem of social care and the role of local government.
	First, on the forward view, everybody should be extremely grateful to Simon Stevens for the leadership that he has shown in bringing forward this document and securing such a large measure of agreement for many of the ideas in it. I very much support his approach of pointing people in a direction of travel but without what I would regard as an overcentralised, detailed game plan or a further reorganisation. The emphasis on local solutions is a big step forward but I want to draw attention to the key funding assumptions underpinning the forward view vision.
	The document acknowledges what many of us have been saying for some time: that the NHS faces a £30 billion funding gap by the end of the decade. It says clearly that this can be closed only by a combination of reducing demand, increasing NHS efficiency and more generous “staged funding increases”, in its words. That is absolutely right, but whether you close that gap depends a great deal on what combination of those assumptions actually takes place. You need everything to work in order to close the funding gap entirely.
	Underpinning all that is a set of assumptions about the efficiency gains that we have talked a bit about today. Under this vision, the NHS is required to achieve an annual efficiency gain of at least 2%, possibly even 3%, for five years on the trot. Its long-run performance is 0.8%, rising recently to about 1.5%, with a big chunk of that 1.5% being achieved by pay restraint—not a card that you can keep on playing year after year. Some would say, “The assumptions on efficiency in this document are heroic, Minister”. As someone who has been in this field a long time, I have to say that I cannot see the NHS sustaining that level of efficiency gain over a five-year period.
	My second point concerns one of the provisos that the Five Year Forward View assumes will actually take place—that is, and this is the document’s term, “sustaining social care”. The reality is that the huge reduction in adult social care funding over the past five years has been a disaster for the NHS. The hospital “bed-blocking” that we so glibly talk about today is in large part a direct result of the draconian cuts in social care funding over that period, which, as the Dilnot commission’s report pointed out in 2011, was in any case underfunded in relation to demography even before the 2010 election. Here I should declare my interest as a member of that committee.
	The continuing tightening of the eligibility criteria for social care has produced an extremely efficient pipeline of frail, elderly people for A&E departments, many of whom then seamlessly become acute hospital bed-blockers. The Better Care Fund is a belated attempt to stop the situation getting worse, but it does little to repair the damage already done and has itself been criticised for its highly bureaucratic approach by one of the Government’s own Ministers, Mr Francis Maude. I have real concerns that unless something is done to tackle the continuing shrinking of the resources for adult social care, the NHS can only get into a worse set of troubles, and many of its patients will receive a poorer service. Acute hospital medical wards are about the last place you want to leave frail elderly people who are confused.
	I close by drawing attention to the issue of local government. Successive Governments have neglected local government; too often they have seen it as the problem rather than part of the solution. I hope that my party will pay attention to this problem. Attention needs to be given to the excellent report for the Labour Party by Sir John Oldham’s independent committee on treating the whole person and integrating care, and not seeing medicine as a collection of professionals attending to various body parts of the individual. Unless we can actually get real about funding and
	about repairing the damage done to adult social care funding and services, we are not going to make much progress in sustaining our NHS.

Baroness Wall of New Barnet: My Lords, I, too, thank my noble friend Lord Turnberg for securing this debate; almost every other speaker has referred to the appropriateness of its timing. I declare an interest as the chairman of Milton Keynes Hospital NHS Foundation Trust, as I will refer to it considerably.
	This debate is about the future of the NHS. I was fortunate as the chairman of Milton Keynes Hospital NHS Foundation Trust to meet a group of young students who have just started their medical training at Milton Keynes Hospital through a partnership that we have just sealed with the University of Buckingham. They were bright, enthusiastic and committed people who are looking forward to their future and, I suggest, to the future of the NHS.
	It perhaps seems appropriate to look back, as other noble Lords have done, at where we are now and what we are learning from where we are, alongside debating and sharing what future this magnificent service can have—a service of which we are proud and which offers care from cradle to grave. My noble friend Lord Turnberg referred to medical and technological interventions and developments, as did other noble Lords in their speeches. As other speakers have said, although these have clearly made a huge difference to people’s lives—and we welcome that—I do not think that any of us realises the strain that has fallen on the hospitals as a result, in particular on acute hospitals that provide these services.
	I will share things that I know happen in my hospital and elsewhere. It is now almost taken for granted that, if a baby is delivered at 22 weeks, it will survive and flourish, which is an admirable thing to achieve. However, to do that, the service required from the NHS is huge as regards the care that that baby needs—in some instances it involves one-to-one specific nursing requirements. The same applies, as other noble Lords have said, at the opposite end of the service. Milton Keynes is a community that includes people of all ages, from the very young to the very old, so it has the same problems as many other hospitals. The interventions and developments that we have had in treating cancer and other medications for improving health, to which noble Lords have referred, have made immense improvements and breakthroughs in people’s lives. However, I am not sure that, as the noble Lord, Lord Desai, rightly said, although in very different terms, we—patients, communities or any of us—understand just what the effect of that is. We all welcome the improvements made in our lives—any of us would want our relations to have all that—but the implications for an acute trust of funding and service provision are extensive.
	Over the last few weeks and even days, my trust, like many others, has been seeing very poor patients, mostly old men and women, brought in with chest pains, breathing difficulties and even with pneumonia, and others are heading that way. We, like other hospitals, have dedicated staff, from consultants and nurses to
	healthcare assistants and, importantly, porters, who are often not mentioned but who make the wheels of the organisation move—porters moving trolleys in and out of A&E can make a big difference to the facility that we have to look after patients, and that support is absolutely crucial, particularly at this time. The staff have a huddle every morning or at every shift change and look at what is going on. If you come in, morning after morning, and find that not a single bed is available for anyone who comes through your doors that day, that is a big challenge to start the day with. However, every member of staff works in high spirits and with complete dedication. They care—as I think we all do—about the type of service that they are going to give. They worry, as we all do, when the stress goes on for as long as it has, that they are not able to give the care that they want each and every patient to have who goes through their hands.
	The reasons for that are multiple and we have discussed many of them today in this debate. I will pick up on one thing that my noble friend Lord Warner just talked about, which is our relationship with local authorities. As my noble friend Lord Warner and other noble Lords said, many of the bed-blockers—it is a most unfortunate phrase; these are wonderful people who have had interesting and dedicated lives—are there because there is nowhere else for them to go. The ability of local authorities to purchase places in nursing homes and care homes, not just in Milton Keynes but elsewhere, has been reduced because of the cuts, so there is nowhere for people to go.
	In addition—and I shall say this quickly, because I am running out of time—what has accelerated the process and caused the overwhelming concern over the past few days is that we have just experienced what in hospital terms is called a “double weekend”. Christmas Day was on Thursday, Boxing Day was on Friday and there followed Saturday and Sunday. The consequences are that we already have challenged services but we also have consultants and nurses who are not working over those days, which means that we cannot provide the usual service.
	The Front Bench is getting anxious that I am not finishing in time, so I will finish there. All that I would seriously ask on behalf of my staff in the hospital is that we should not have massive change. Please let us not have a whole new look at what we are doing, with someone coming out with something entirely different. Everybody is weary with that, so let us just look at what we have and make sure that we can make it work better.

Lord Mawson: My Lords, I thank the House for allowing me to speak briefly in the gap. In the debate led by the noble Lord, Lord Kakkar, in November, on health and innovation, I described a piece of health innovation that I am leading in Tower Hamlets, bringing a health centre, a school, housing and a whole range of enterprise projects together in an integrated health and education project. Professor Brian Cox and I are embedding a science summer school in this project, focused on how Britain becomes the best place to do science in the world. It has taken us seven years to create the health centre; we have lived through three
	different Governments. I have to thank the noble Earl, Lord Howe, for helping us to resolve this issue; it is very good news indeed.
	What lessons have we learnt from a real project on the ground over the past seven years? My first point is that we need consistency. The message and the people constantly change. Secondly, there needs to be accountability. No one seems able to take a decision; there are layers and layers of approval processes, requiring business case after business case, then point one comes in—I refer to my point about consistency—and you are back to square one.
	Thirdly, we need clarity. To the outside the world, the NHS is the NHS is the NHS. Unfortunately, within the NHS there are so many silos that only the NHS can understand, which all have to have their say and they all have different approval mechanisms. Then, because of the accountability processes, nobody can take a decision, so it becomes a game of “We will agree if they will agree”, with no one willing to make a final call.
	Fourthly, there must be local empowerment. The centre has to make all the decisions but it is the people on the ground at a local level who should be leading. Locally, things are either done to you from the centre or not done at all.
	Fifthly, there needs to be partnership and trust. We are not all the evil private sector, all out to screw the NHS. Partnership can achieve so much and has done so to date. The NHS has got to learn to trust and work with others, and it may just find that it can benefit enormously. The best local authorities have made real progress here, but the NHS by and large has not. Our project is bringing large amounts of money, which are coming from outside the NHS budget, into health initiatives on a housing estate. That is what partnership does.
	Sixthly, on primary care premises development, the Secretary of State is continually talking about moving to a more preventive and proactive approach, and he is right to do so. To do this, you need to do all that I have mentioned above. However, NHS estates have been given a very narrow, financially driven brief. They need fresh instruction and leadership with a specific brief to foster partnership and opportunities for GP practice developments that will then deliver a preventive and cost-effective, proactive approach. They need to be the solution, not the problem—because not despite.
	Most importantly, it must be about patients, patients, patients. Some parts of the NHS seem to have forgotten all about that.

Lord Hunt of Kings Heath: My Lords, as this is a general debate on the NHS, I remind the House of my interests as a consultant trainer with Cumberlege Connections and president of GS1. As I am going to raise the Cancer Drugs Fund, I also declare that a relative of mine, Joe Wildy, is an employer in the government affairs department of Sanofi.
	I, too, congratulate my noble friend Lord Turnberg on securing the debate and on the quality and breadth
	of his opening speech. It is clearly timely; never has the health and social care system been under so much pressure.
	As many noble Lords have suggested, this pressure can only grow with technological and medical advances, and the sheer fact that the number of those aged over 80 will double by 2037. Implicit in the Motion of the noble Lord, Lord Turnberg, is the question of whether a comprehensive service is still feasible and affordable. I have no doubt that it is but nor do I doubt the scale of the change that the NHS must effect to ensure that sustainability. I have identified seven key areas of change. First, we have to undo the damage caused by the Government’s 2012 Act without undergoing a huge restructuring, as my noble friend Lady Wall said. Secondly, we have to ensure a sustainable funding regime for the NHS and social care. Thirdly, we have to integrate health, mental health and social care. Fourthly, we have to invest in and re-energise primary care. Fifthly, we need a much more assertive public health programme. Sixthly, we need more personalised care and innovation and, seventhly, we have to invest in and support a workforce to help us transform services.
	It is a truth universally acknowledged that the 2012 Act has been pretty much a disaster. Despite all the protestations of Ministers, a huge amount of money has been spent and services have been fragmented, and too much energy is spent by all the players simply trying to keep the new system’s head above water. At a time of real crisis in emergency services, it is palpably clear that no one is in charge locally or nationally. My noble friends Lady Jay and Lady Wilkins, and the noble Lord, Lord Mawson, identified the buck-passing of responsibility between a mishmash of clinical commissioning groups, commissioning support units, local area teams and health and well-being boards, which are all quite unable to show the required leadership.
	It is the same at national level. Ministers, the Department of Health, NHS England, the NHS Trust Development Authority, Monitor and the CQC vie with each other, often conflict and certainly provide no clear leadership. No wonder the National Audit Office commented in November that it is not at all clear where responsibility for strategic change lies. Quite! It is not surprising that performance is problematic. The Government inherited an NHS that was meeting the then 98% four-hour A&E target. They reduced that to 95% but hospital A&Es have missed that target for 76 weeks, with many hospitals in the last two weeks declaring major incidents. It is clear that the service is under extreme pressure.
	On resources, never has the NHS had to cope with a flat-line budget—which is essentially what it is—for such a long time in its history. The recent NAO report on the financial sustainability of the NHS makes for sober reading, as does NHS England’s Five Year ForwardView. My noble friend Lord Liddle pointed out that the Chancellor’s intention to reduce public expenditure to 35% of GDP by the end of the Parliament means that the actual resources going to the NHS will be bleak indeed.
	I want to ask the noble Earl about an aspect of the immediate funding problem, which concerns the Cancer Drugs Fund. In August last year, the Government
	announced additional funds for the CDF to ensure that as many people as possible could access these pioneering, life-enhancing drugs. However, I understand that six months later NHS England is poised to remove that access for unknown thousands of patients. What is the Government’s policy on the CDF?
	I ask the noble Earl yet again about the money now being paid back by the pharmaceutical industry to underpin the cost of certain drugs, subject to a modest inflation figure every year. Where is this money being spent? Why is it not being spent on new medicines and new treatments, where surely it ought to go? Is it a fact that NHS England does not accept the agreement that the department reached, and that is why it is not playing ball in ensuring that the money is invested where surely it ought to be invested?
	On funding, my party has committed itself to a £2.5 billion Time to Care fund. We also want to remove some of the wasteful costs of the current restructuring. However, we should listen to my noble friend Lord Warner on the gap identified by NHS England. The fact is that the 3% efficiency target is formidable or heroic, as he said. We will have to tackle this one way or another.
	We also have to tackle the integration of physical health, mental health and social services. We need personal care plans and a single point of contact. We can see the current problems, which my noble friend Lady Wall identified. We see the fruits of a lack of integration. First, adult care has been impossibly squeezed. This has forced frail older people to rely on the NHS as the provider of last resort. It also means much less support for people when they are ready for discharge from hospital. Delays then happen, with longer lengths of stay. That is the problem we face. Without a properly resourced social care system, and without integration, we are not going to be able to move away from it.
	Then there is primary care. Is it any wonder that A&Es throughout the country—recently the Great Western trust in the south-west, the Walsall trust in the Midlands and the Royal Surrey County Hospital in Guildford—are having to warn patients to stay away? It is no wonder when people find it so difficult to see their GP. In the east Midlands, the CCG in Erewash reported that one in five patients had to wait a week for a doctor’s appointment. Barnsley Hospital in South Yorkshire recently surveyed patients, many of whom complained about difficulties in getting a local GP appointment. This has to be tackled. I remind the Minister that whatever one says about the contract, the fact is that this was not a problem in 2010, even though the period between 1997 and 2010 had seen a steady increase in the number of patients coming through the door.
	Investment in primary care has definitely fallen behind, and a workforce crisis is emerging. One good start would be for the Secretary of State to desist from his thoughtless attacks on GPs. We have pledged to use part of our £2.5 billion Time to Care fund to recruit more GPs, but we need to do much more to bring GPs into the core of the system. I remind the noble Earl, Lord Howe, that when Andrew Lansley proposed the 2012 reforms, he said that the reason was that, “GPs
	spend all the money and we want to give them the levers because that will effect change”. However, the huge gap in the system is that clinical commissioning groups seem to have no impact whatever on the performance and behaviour of GPs. I thought that that was the whole purpose of delegating budgets to CCGs. The reason, of course, is that the contract is held with NHS England, which has been quite unable to impact on the performance of GPs.
	My noble friend Lord Rea talked about public health. I certainly agree with him and NHS England on its five-year plan. It says that we need a radical upgrade in prevention and public health. It says that it will back hard-hitting national action on obesity, smoking, alcohol and other major health risks. That is very welcome. The question I would ask the noble Earl, Lord Howe, is whether the Government will let NHS England do that—because I have to say that the Government’s record on public health has been very disappointing indeed.
	There is one other area that I have time to mention: the adoption of innovation in the National Health Service. The noble Earl knows that he and I share the concern about the slowness of the NHS to adopt new treatments and new medicines. Surely, given our fantastic life sciences, and the strength of our pharma and medical devices industries, we have to find a way to encourage the NHS to move to adoption much more quickly than heretofore. I certainly hope that in his winding-up speech he can say a little more about how we are going to do that.

Earl Howe: My Lords, I start by congratulating the noble Lord, Lord Turnberg, on securing this debate and thanking those noble Lords who have contributed to it.
	As noble Lords will know, having covered the health portfolio continuously since 1997, I still find myself continuously in awe of the NHS and the principles that underpin it, as well as of the people within our health service who live out these principles, not least at the moment.
	The NHS is currently facing challenges that it has never faced before. Even though the Government have protected the NHS with real-terms funding increases, we do not underestimate how challenging it has been to continue to deliver high-quality care in the current climate. Demand for healthcare is rising and changing as the population ages and different diseases come to the fore. We are faced with an ageing population, as has been said, and one where increasing numbers of people are living with multiple chronic conditions. The big issues that the NHS must deal with now, such as dementia and lifestyle conditions such as obesity, cannot be addressed by the traditional model of a healthcare system which is focused on the acute sector.
	I want to spend most of my speech considering the future of the NHS following the recent publication of the Five Year Forward View. This document, which was published jointly by NHS England and five other arm’s-length bodies, sets out a vision for how our health system will evolve over the next five years. It is a
	vision which the Government share. The Secretary of State and I have previously set out the four pillars of our response, which are worth recapping.
	The first pillar is to ensure that we have an economy that is able to pay for the growing costs of our NHS and social care system. A strong NHS needs a strong economy. The success of our economy means that we were able to provide additional funding in the Autumn Statement, including £1.7 billion to support and modernise the delivery of front-line care, and £1 billion of funding over four years for investment in new primary care infrastructure. In all, NHS funding will be about £3 billion more next year compared with this year, and all that extra funding will be baselined for future years.
	The NHS itself contributes to that strong economy in a number of ways, and we want to help it to develop its role. It is helping people with mental health conditions to get back to work by offering talking therapies to 100,000 more people every year than four years ago. The NHS can also attract jobs to the UK by playing a pivotal role in our emerging life sciences industries. In the past three years, we have attracted £3.5 billion of investment and 11,000 jobs. This Government have set out our ambition to be the first country in the world to decode 100,000 research-ready whole genomes.
	The second pillar of our plan is to change the models of care to be more suited for an ageing population. As I said earlier, we need to accommodate growing numbers of vulnerable older people who need support to live better at home with long-term conditions such as dementia, diabetes and arthritis. To do that, we need a greater focus on prevention, which will help people to stay healthy and not allow illnesses to deteriorate to the point where they need expensive hospital treatment.
	This Government have already made good progress in improving out-of-hospital care. Last year, all those aged 75 and over were given a named GP responsible for their care—something that was abolished by the previous Government. From April, everyone will have a named GP. Already 3.5 million people benefit from our introduction of evening and weekend GP appointments, which will progressively become available to the whole population by 2020. The better care fund is integrating the health and social care systems to provide joined-up care for our most vulnerable patients. Alongside that, the Government have legislated, for the first time ever, on parity of esteem between physical and mental health.
	However, I recognise that there is more to do. NHS England has already invited applications from local areas for the £200 million of funding which has been made available to pilot the new models of care set out in the Five Year Forward View. To deliver these new models, we will need to support the new clinical commissioning groups in taking responsibility, with their local partners, for the entire health and care needs of people in their area.
	A strong economy and a focus on prevention are the first two pillars of our plan. The third pillar is to be much better at embracing innovation and eliminating waste. Previously, the NHS has often been too slow to adopt and spread innovation. Sometimes this has been because the people buying healthcare have not had the information to see how much smart purchasing can
	contain costs. From this year, CCGs will have access to improved financial information, including per-patient costings. The best way to encourage investment in innovation is a stable financial environment. Following the next spending review, local authorities and CCGs will receive multi-year budgets. The NHS also needs to be better at controlling costs in areas such as procurement and agency staff as well as reducing litigation and other costs associated with poor care. We are working with NHS England and partner organisations to agree the level of savings in each area, which will allow more resources to be directed to patient care.
	The final pillar of our plan is to continue to develop a culture of care in all parts of the NHS. We have made good progress since the Francis report. We have introduced a greater focus on patient care. There are 5,000 more nurses on our wards and 4.2 million NHS patients have been asked, for the first time, if they would recommend to others the care they received. We plan to go further over the next few months. We will set out how we will improve training and safety for new doctors and nurses, launch a national campaign to reduce sepsis, and, responding to recommendations made in the follow-up Francis report, tackle issues of whistleblowing and the ability to speak out easily about poor care.
	Noble Lords have raised a number of other important issues in this debate. I shall endeavour to respond to as many as I have time to do. First, I shall talk about funding, a subject covered very thoughtfully by the noble Lord, Lord Turnberg, my noble friends Lord Horam and Lord Cormack, and the noble Lord, Lord Liddle, among others. The Five Year Forward View argued that a combination of growing demand and no further efficiencies would bring about a funding gap for the NHS of nearly £30 billion by 2020-21 against a flat real baseline. A 2% efficiency growth, rising to 3% over time, produces a remaining gap of £8 billion. But if the NHS can achieve 3% efficiency gains, the remaining challenge would reduce to around £4.4 billion in 2020-21. I will talk about the scope for efficiencies in a moment, but this is broadly the same real-terms funding increase that the Government have committed to the NHS over this Parliament.
	The funding announced in the Autumn Statement fully delivers the investment required to make the Five Year Forward View a reality in 2015-16 and provides funding to start delivering the changes required by the Five Year Forward View to deliver a sustainable NHS in future years. As I have said, this new funding will be baselined for future years. As has happened over this Parliament, real increases in funding will be required to complete this transformation and ensure a sustainable NHS in the future but the NHS will also be required to make significant efficiencies. Of course, I cannot go further than that at the moment because the detailed funding package for 2016-17 onwards will be announced at the next spending review, whichever party is in government. It is worth pointing out that all the £1.5 billion of investment in NHS front-line patient care in 2015, stemming from the Autumn Statement, will go to improving local NHS services and will help the NHS to meet rising demand. On top of that, we are introducing a £200 million transformation fund. The fund will kick-start the work needed to
	develop new ways of caring for patients which do a better job of joining up GPs, community services and hospitals.
	In part of her speech, the noble Baroness, Lady Jay, focused on competition. I am sure she will remember that greater competition in the NHS was introduced through deliberate policies from 2003, such as the independent sector treatment centres and choice of any willing provider. Rules were put in place in 2007 to manage this competition. We as a government continued that approach of managed competition, overseen, however, by an expert health regulator in the shape of Monitor. I would just say that this has hardly led to a giant expansion of private provision. Commissioner spending on healthcare from private sector providers equates to about 6.1% of total NHS revenue expenditure, which is only 1.2% more of the NHS budget than in 2010. Much of the increase is accounted for by social enterprises and charities, which I know the party opposite supports.
	The key here is that it is not politicians who take these commissioning decisions but clinicians. As the noble Baroness conceded, there has not been a change in the Secretary of State’s core duty. He is responsible for promoting a comprehensive health service. This remains consistent with the wording of the original 1946 Act. At the same time, what the Act also did was right. The Health and Social Care Act puts clinicians in charge of decision-making about patients rather than politicians or administrators. That involves a strengthening of local accountability and decision-making through clinical commissioning groups and local health and well-being boards. Local authorities are once again responsible for public health, as my noble friend Lady Barker reminded us. We have also restored a culture of care to the health service so that doctors are primarily accountable to their patients, not top down targets or bureaucrats. I simply say to the noble Baroness, Lady Jay, and the noble Lords, Lord Morris and Lord Hunt, that any future Government would reverse those measures at their peril.
	The noble Lord, Lord Turnberg, said that the NHS should become a much more preventive service and we fully agree with that. Action is needed to address the common risk factors for the big killer diseases. To give one example, the NHS health check provides an opportunity to review an individual’s health against some of the risk factors that he listed. Last year, more people than ever before received a free NHS health check. Since it was introduced, 7.5 million offers have been made and more than 3.7 million NHS health checks have been received, offering a real opportunity to reduce avoidable deaths and disability and to tackle health inequalities.
	My noble friend Lord Balfe spoke about GPs and, in particular, GP access. We are introducing a number of measures to ensure that people who need to see a GP do so at a time to suit them. We have invested through the Prime Minister’s Challenge Fund £50 million this year to help more than 1,100 practices to develop new ways of improving GP access. We have committed to invest another £100 million into the scheme next year and we will extend seven-day opening to every patient in the country by 2020. From January, practices will also be allowed to register people outside their
	local area, making it easier for hard-working people to register near their place of work or somewhere else that is convenient to them. Despite a decrease in head count, there has been a 1.2% increase in full-time equivalent GPs since 2012 and the number of practice nurses and other practice staff has also grown, representing in total a real capacity increase.
	The noble Lord, Lord Rea, focused on alcohol, an important issue. We are committed to reducing alcohol-related harm and have already banned alcohol sales below the level of duty plus VAT, meaning that it will no longer be legal to sell a can of ordinary lager for less than around 40p. Alcohol consumption per head has fallen, I am pleased to say, in recent years. Reduced affordability of alcohol, influenced by tax rises up to 2013, has been a factor in this. Alcohol minimum unit pricing is still being considered as a possible way forward but no decision has been taken.
	The noble Baronesses, Lady Masham and Lady Wilkins, turned our attention to spinal injury services. The NHS England spinal cord injuries service specification clearly sets out what providers must have in place to offer evidence-based safe and effective services. It sets a core requirement that each specialised SCI centre can demonstrate that it has a minimum of 20 beds dedicated exclusively for the treatment and rehabilitation of SCI patients. The overall bed complement for England is being reviewed through a demand and capacity project led by the Spinal Cord Injury Clinical Reference Group. That group aims to produce a report in 2015-16.
	The noble Baroness, Lady Wilkins, argued for a strategic view of spinal injury services. As she knows, NHS England commissions specialised rehabilitation services as defined by the service specification, which sets out what providers must have in place to offer safe and effective specialised rehabilitation services. The clinical reference group is currently completing a review of those services. It will involve establishing nationally what the current demand is for rehabilitation services, which must be the first point of reference.
	My noble friend Lord Horam spoke about bed blocking and asked whether some of the delayed discharges could be resolved by discharge to mental health trusts or housing associations, and whether local areas could do more than they are doing. I would simply say to him that these things have to be dealt with locally; we cannot hope to do it centrally. The Health and Social Care Act 2012 gives local clinicians more power and responsibility to develop the right solutions for their local areas. Hospital trusts are already forming effective partnerships to ensure that patients get the support they need to be discharged from hospital quickly, and I can tell him that NHS England and others are supporting them to do this.
	My noble friend Lady Barker focused part of her speech on mental health. I fully agree with her that public services should reflect the importance of mental health, putting it on a par with physical health, as we have argued so often. Parity of esteem between mental and physical health is now enshrined in legislation. For the first time, we have introduced waiting time standards for mental health, ensuring that NHS England and local partners properly prioritise access to mental health services, and we have made mental health part
	of the new national measure of well-being so that it is more likely to be taken into account when government departments are developing and implementing policy.
	The noble Lord, Lord Kakkar, in his wide-ranging speech, covered a number of key issues. I turn first to efficiency savings. There is no doubt that the NHS needs to be better at controlling costs in areas such as the procurement of medicines and clinical equipment, and indeed non-clinical equipment, energy and fuel, agency staff, the collection of fees from international visitors, and reducing litigation and other costs associated with poor care. Gains can also be made in ways of working, such as by getting paramedic teams to treat more patients at home rather than bringing them to hospital; creating more regional centres of excellence for specialist treatments such as stroke and heart disease; bringing more services out of hospital and into the community by, for instance, having specialist consultants in GP surgeries; offering more patients better access to GPs, including evening and weekend appointments and Skype consultations; and joining up health and social care services such as through the Better Care Fund. Working with NHS England, the department has announced plans in all these areas. We will agree the precise level of savings to be achieved through consultation with NHS partner organisations over the next six months. That will lead to a compact signed up to by the department, its arm’s-length bodies and local NHS organisations with agreed plans to eliminate waste, thus allowing more resources to be directed to patient care.
	The noble Lord, Lord Hunt, asked me about the cancer drugs fund. Of course, the policy behind this is to give patients access to the drugs they need, but I would qualify that by saying that those drugs need to be clinically effective. That is the reason why NHS England is doing the sifting process that is currently in train. The payments from industry that he referred to were never going to be hypothecated; they form part of NHS England’s general budget. Having said that, NHS England does have the freedom to apply the money as it sees fit, whether that is for drugs, radiotherapy, or indeed any other investment that it deems to be clinically effective.
	Moving back to the noble Lord, Lord Kakkar, who asked me about innovation, the appropriate use of technology-enabled care services such as telehealth and telecare can support patients in managing their long-term conditions more effectively and enable people with social care needs to live independently for longer. We are making progress in this area, and I will be happy to bring him up to date by letter on that. As regards the new NHS Innovation Accelerator programme announced yesterday, I agree with him that that is very good news. It invites leading healthcare pioneers from around the world to bring their tried and tested innovations to the NHS. Again, I can expand on that by letter.
	Where are we with the personalised medicine agenda, informatics and the UK Biobank? I can say to him, as I can to my noble friend Lady Thomas, that we are determined to make Britain the best place in the world to discover and develop 21st century medicines. By harnessing the UK’s unique strengths in research, the NHS, medical charities and a vibrant life sciences
	cluster of innovative companies, we are sure that we can accelerate access to new treatments and attract major new investment and growth.
	I will need to leave the other questions to the letter that I have promised to send round to all noble Lords who have spoken. However, suffice it to say for now that in recognising that the NHS faces some definite challenges as we strive to increase both the efficiency and quality of care, we also have a clear plan for how we are going to tackle this. The progress that we want to make will only be made possible by people: those who work in the NHS and those who rely on it. We need to free people up to make decisions about the NHS, creating models of care that suit local needs while upholding a world-class standard. I am confident that we can do that together.

Lord Turnberg: My Lords, I thank all noble Lords for their wide-ranging and well informed contributions. I have learnt a lot. I clearly cannot comment on every noble Lord’s contribution, but I particularly wanted to say how pleased I was to hear from the noble Baroness, Lady Wilkins, who is back in her place and in fine voice.
	Clearly, we were never going to solve all the problems of the NHS today, but I believe that this debate has been a useful contribution as we ease our way into the next election. The next Government will have to level with the public, who are very supportive of the NHS, and grapple with the issue of how we might cope with the conundrum of paying for a service that becomes more complex as every day goes by.
	Of course we should become more efficient, but I am reminded that Aneurin Bevan, when the NHS began, thought that as we cured and prevented more diseases the service would get cheaper. However, every year it seems to have got more expensive, and as we cure one disease, another disease pops up. It is an unfortunate fact that the mortality rate among humans is almost 100%—exactly 100%. On that happy note, once again I thank all noble Lords for their contributions and look forward to the next Government’s actions as a result.
	Motion agreed.

Insurance Bill [HL]
	 — 
	Report

Clause 4: Knowledge of insured
	Amendment 1
	 Moved by Lord Newby
	1: Clause 4, page 3, line 16, leave out from “(whether” to “the” in line 17

Lord Newby: My Lords, in moving Amendment 1, I shall also speak to Amendment 2. In the amended Bill, Clause 4(6) provides that, for the purposes of the duty of fair presentation of the risk, the insured “ought to know” what should have been revealed by a “reasonable search of information” available to it.
	Some of the evidence we heard in Committee made the case for the Bill explicitly confirming that the “reasonable” search may extend to persons covered by the insurance contract but who are not the insured in the sense of being a contracting party. Noble Lords will recall that my noble friend Lady Noakes and the noble and learned Lord, Lord Woolf, put forward amendments to this clause in Committee stating that the reasonable search may extend to persons who could benefit from the contract. The Government were unable to agree with the specific wording of those amendments, and they were subsequently withdrawn.
	However, we agreed to take the issue away and consider whether amendments needed to be made to ensure that the intended scope of the clause is clear. The Government consider that such clarification would benefit the Bill, and Amendments 1 and 2 seek to address this issue. As we discussed in Committee, what is a reasonable search of information will depend on the type of cover an insured seeks and the type of entity it is. It is important that Clause 4(6) expresses a broad principle that is flexible enough to take account of the wide variety of insurance policies and types of cover which are bought in the non-consumer context.
	Amendment 2 clarifies that “information” which an insured ought to know may include information held by a person other than the insured, specifically mentioning that this may include,
	“a person for whom cover is provided by the contract of insurance”.
	This makes clear that persons benefiting from the contract could come within the scope of the insured’s reasonable search. I believe that this was at the heart of the amendments put forward by my noble friend Lady Noakes and the noble and learned Lord, Lord Woolf, and I hope that they are content with the drafting we have produced on this in Amendment 2. These amendments will improve the Bill, and I hope that the House can support them. I beg to move.

Lord Woolf: My Lords, in accord with the approach adopted by the Minister throughout the discussions on this Bill, I would like to acknowledge the help that he gave, which was something that I and the noble Baroness, Lady Noakes, were looking for.
	Amendment 1 agreed.
	Amendment 2
	 Moved by Lord Newby
	2: Clause 4, page 3, line 18, at end insert—
	“( ) In subsection (6) “information” includes information held within the insured’s organisation or by any other person (such as the insured’s agent or a person for whom cover is provided by the contract of insurance).”
	Amendment 2 agreed.
	Amendment 3
	 Moved by Lord Newby
	3: After Clause 10, insert the following new Clause—
	“Terms not relevant to the actual loss
	(1) This section applies to a term (express or implied) of a contract of insurance, other than a term defining the risk as a whole, if compliance with it would tend to reduce the risk of one or more of the following—
	(a) loss of a particular kind,
	(b) loss at a particular location,
	(c) loss at a particular time.
	(2) If a loss occurs, and the term has not been complied with, the insurer may not rely on the non-compliance to exclude, limit or discharge its liability under the contract for the loss if the insured satisfies subsection (3).
	(3) The insured satisfies this subsection if it shows that the non-compliance with the term could not have increased the risk of the loss which actually occurred in the circumstances in which it occurred.
	(4) This section may apply in addition to section 10.”

Lord Newby: My Lords, Amendment 3 is, with a few slight amendments, the text which the noble and learned Lord, Lord Woolf, put forward in Committee concerning terms not relevant to the actual loss. It is intended to prevent an insurer from relying on a policyholder’s non-compliance with a warranty or other contract term in order to avoid liability for an insurance claim for loss of an entirely different kind.
	From the outset, the policy aim behind this amendment has been generally well supported. There were some concerns about the drafting of the clause, which meant that it did not achieve a sufficient consensus of support such that it could be introduced as part of an uncontroversial Bill. The text of this amendment was proposed and consulted on by the Law Commission after the introduction of the Bill as a drafting solution which, it was hoped, would be suitable for this non-controversial parliamentary procedure.
	I am very pleased that the written and oral evidence put to the committee, together with the backing of the committee members themselves, has demonstrated a strong body of support for this formulation. As such, the Government consider it suitable to be included in this Bill. It complements the existing Clause 10, which makes changes to an insurer’s remedy for breach of warranty. I beg to move.
	Amendment 3 agreed.
	Clause 12: Remedies for fraudulent claims: group insurance
	Amendment 4
	 Moved by Lord Newby
	4: Clause 12, page 6, line 32, leave out subsection (1) and insert—
	“(1) This section applies where—
	(a) a contract of insurance is entered into with an insurer by a person (“A”),
	(b) the contract provides cover for one or more other persons who are not parties to the contract (“the Cs”), whether or not it also provides cover of any kind for A or another insured party, and
	(c) a fraudulent claim is made under the contract by or on behalf of one of the Cs (“CF”).”

Lord Newby: My Lords, I shall speak also to Amendments 5 to 9 and manuscript Amendment 10A, which has been tabled in substitution for Amendment 10. The amendments respond to representations made to the committee that Clause 12 on fraudulent claims in
	consumer group insurance should be extended to group insurance contracts in the non-consumer context. My noble friend Lady Noakes tabled amendments on this point in Committee. The Government supported this change in principle but were unable to support the specific amendments suggested by my noble friend. As such, her amendments were withdrawn on the basis that the issue would be taken away and considered further.
	We have now had the opportunity to consider the amendments needed to the Bill in order to effect this change. Clause 12 currently provides that where a member of a group consumer insurance contract makes a fraudulent claim, the insurer has a remedy against the fraudulent group member but the remaining members of the group policy are protected. Amendments 4 and 5 extend the application of Clause 12 to the non-consumer context, and indeed in respect of contracts that cover both consumers and non-consumers as group members under the same policy. Amendments 6 and 7 correct a small error in Clause 12(3) that was spotted when drafting the main amendment to the clause.
	Amendments 8, 9 and 10A deal with contracting out. In the consumer context, an insurer will not be able to put a consumer group member in a worse position than they would be in under Clause 12. In the non-consumer context, an insurer will have to comply with the transparency requirements if they wish to put a group member in a worse position. These provisions are consistent with the contracting-out provisions generally, and are a necessary consequence of extending Clause 12 to non-consumers. I should explain that the only difference between Amendment 10A and Amendment 10, which it replaces, is that the various cross-references to other sections have been corrected.
	I believe that these amendments fully address the desire of the committee, particularly my noble friend Lady Noakes, and a number of the committee’s witnesses to extend the application of Clause 12 to the non-consumer context. These are uncontroversial amendments and I hope therefore that noble Lords can support them. I beg to move.

Lord Young of Norwood Green: My Lords, I thought it would be appropriate for us to say that we support these amendments. It is a good example of Parliament working to improve a valuable service industry, enhancing its position globally. That is important because the UK is a world leader in this. It is not a subject that I profess a great deal of knowledge about but I cannot help having a slight ironic feeling. My late father, who was a very successful insurance agent, would have been pleased to hear my contribution, brief though it is.
	Amendment 4 agreed.
	Amendments 5 to 7
	 Moved by Lord Newby
	5: Clause 12, page 6, line 42, leave out “consumer”
	6: Clause 12, page 7, line 7, after first “the” insert “first”
	7: Clause 12, page 7, line 10, at end insert—
	“( ) the second reference to “the insured” in subsection (1)(b) is to A or CF,”
	Amendments 5 to 7 agreed.
	Clause 14: Contracting out: consumer insurance contracts
	Amendment 8
	 Moved by Lord Newby
	8: Clause 14, page 8, line 3, leave out paragraph (b)
	Amendment 8 agreed.
	Clause 15: Contracting out: non-consumer insurance contracts
	Amendment 9
	 Moved by Lord Newby
	9: Clause 15, page 8, line 18, leave out subsection (3)
	Amendment 9 agreed.
	Amendment 10A (in substitution for Amendment 10)
	 Moved by Lord Newby
	10A:After Clause 16, insert the following new Clause—
	“Contracting out: group insurance contracts
	(1) This section applies to a contract of insurance referred to in section 12(1)(a); and in this section—
	“A” and “the Cs” have the same meaning as in section 12,
	“consumer C” means an individual who is one of the Cs, where the cover provided by the contract for that individual would have been a consumer insurance contract if entered into by that person rather than by A, and
	“non-consumer C” means any of the Cs who is not a consumer C.
	(2) A term of the contract of insurance, or any other contract, which puts a consumer C in a worse position as respects any matter dealt with in section 12 than that individual would be in by virtue of that section is to that extent of no effect.
	(3) A term of the contract of insurance, or any other contract, which puts a non-consumer C in a worse position as respects any matter dealt with in section 12 than that person would be in by virtue of that section is to that extent of no effect, unless the requirements of section 16 have been met in relation to the term.
	(4) Section 16 applies in relation to such a term as it applies to a term mentioned in section 15(2), with references to the insured being read as references to A rather than the non-consumer C.
	(5) In this section references to a contract include a variation.
	(6) This section does not apply in relation to a contract for the settlement of a claim arising under a contract of insurance to which this section applies.”
	Amendment 10A agreed.

House adjourned at 5.42 pm.